Instruments to Assess Family Focused Care in Nursing Clinical Practice: A Systematic Review of Psychometric Properties

ABSTRACT

Aims

To identify, appraise and describe the characteristics and measurement properties of instruments assessing Family Focused Care in nursing clinical practice using COSMIN criteria.

Design

A systematic review based on COSMIN methodology.

Methods

Methodological quality was assessed using COSMIN methodology and evidence quality using the GRADE approach modified by COSMIN.

Data Sources

The databases PubMed, CINAHL, COCHRANE, Web of Science and SCOPUS were systematically searched from inception until September 2024.

Results

A total of 47 studies and 15 instruments evaluating Family Focused Care were included. Seven were designed for measuring professional's perspective, six for family's and two for both. Three instruments, the Family Nursing Practice Scale (FNPS), the Iceland Family Perceived Support Questionnaire (ICE‐FPSQ) and the Perception of Family Centred Care Staff and Parents (PFCC‐S/P), exhibited the highest methodological quality and robust psychometric properties, including internal consistency, structural validity, reliability and content validity.

Conclusion

The FNPS, the ICE‐FPSQ and the PFCC‐S/P questionnaires were identified as the most suitable instruments to assess Family Focused Care. Future research should rigorously evaluate their psychometric properties.

Implications for the Profession and/or Patient Care

This review provides insight into available instruments for measuring Family Focused Care, helping professionals choose the most suitable tools to enhance family involvement, align care with family needs, and improve patient outcomes and family well‐being.

Impact

Given that the psychometric properties of instruments measuring Family Focused Care have not been systematically assessed, the present review utilised comprehensive methods according to COSMIN.

Patient or Public Contribution

No Patient or Public Contribution.

Reporting Method

PRISMA statement and COSMIN reporting guideline for studies on measurement properties of patient‐reported outcome measures.

Protocol Registration

This systematic review has been registered at the International Prospective REGISTER of Systematic Review (PROSPERO: CRD42022315249).

Summary.

• What does this paper contribute to the wider global community?

  • ○
    This review identifies and evaluates 15 reliable and validated instruments for assessing Family Focused Care, providing a valuable resource for researchers and clinicians.
  • ○
    Three instruments are recommended for assessing Family Focused Care: the Family Nursing Practice Scale, the Iceland Family Perceived Support Questionnaire, and the Perception of Family Centred Care Staff and Parents questionnaire. These tools demonstrated higher methodological quality, overall rating, and quality of evidence according to COSMIN guidelines.
  • ○
    This review provides healthcare professionals and researchers a detailed overview of available instruments assessing Family Focused Care, facilitating informed selection for clinical practice and research purposes.

1. Introduction

When an illness or disability disrupts a family, the impact can be profound and transformative. The illness experience not only affects the individual directly involved but also all family members, influencing their emotional, psychological and social well‐being (Shajani and Snell 2023). Families often play a crucial role in supporting and caring for their ill relatives, acting as principal caregivers and providing both practical and emotional support (Blöndal et al. 2014; Fernandes et al. 2018). The family's capacity to adapt and cope with these situations significantly influences the overall health outcomes of the patient and the family unit itself.

Acknowledging the vital role of families in healthcare has led to an increasing emphasis on their involvement in the care process (Matziou et al. 2018; Shields and Tanner 2004). In response, various care models have emerged to integrate the family alongside the patient, with Family Nursing, Family Centred Care, and Family Focused Care being among the most widely adopted. These models advocate for considering the family as a unit of care, rather than focusing exclusively on the individual patient (Shields 2015; Svavarsdottir et al. 2025).

Family Nursing simultaneously focuses both on the individual and on the family unit with particular attention to the interaction, reciprocity and circularity between the patient and other family members. Its primary goal is to maintain family health and foster healing, promoting both health and relief from illness‐related suffering (Wright and Leahey 2013). On the other hand, Family Centred Care (FCC) emphasises collaboration and partnership between healthcare professionals and family members, particularly through shared decision‐making processes (Kuo et al. 2012).

Family Focused Care (FFC) is an approach in which health and social care professionals actively respect and address the needs of both the individual and their family as a complete unit, recognising the family role in supporting the patient. For the purpose of this review, FFC is used as an umbrella term encompassing ‘family centred care’, ‘family oriented care and ‘family nursing’.

The benefits of FFC care in clinical practice are well‐documented. Research has shown that involving families in healthcare decisions improves communication, increases treatment adherence, and boosts patient and family satisfaction. Patients report higher satisfaction levels with care and increased self‐efficacy (Dowling et al. 2005; Vahedian Azimi et al. 2010), along with improved symptom management and the ability to develop healthy behaviours (Gilliss et al. 2019). Families experience enhanced communication patterns, greater satisfaction with care received, and reduced depression symptoms (Lolaty et al. 2014; Dowling et al. 2005; Mashhadi et al. 2021). It can also mitigate the emotional burden experienced by families, fostering resilience and promoting a supportive environment for recovery. Additionally, healthcare professionals offering Family Focused Care demonstrate reduced burnout, increased self‐esteem, competence, and job satisfaction, ultimately leading to an improvement in the quality of care provided (Yang et al. 2023; Duhamel et al. 2015). These positive outcomes are observed across a wide range of clinical settings and populations, as Family Focused Care is applied throughout the lifespan from paediatric patients to the elderly (Clay and Parsh 2016). Consequently, integrating family focused practices into nursing care not only benefits patients but also strengthens the family unit's ability to cope with health challenges.

Given the importance of family involvement in care, it is essential to assess how family focused practices are implemented and perceived (Barnes et al. 2024; Shamali et al. 2025). Evaluating the degree to which nursing practices are family focused requires valid and reliable measurement tools (Curley et al. 2013). These instruments allow healthcare professionals and researchers to identify strengths and areas for improvement in family care, ultimately guiding evidence‐based interventions and policy development (Akkaş and Geçkil 2023).

Selecting an appropriate measurement instrument requires quality studies documenting the evaluation of measurement properties, as well as high‐quality systematic reviews of psychometric properties (Mokkink et al. 2024; Prinsen et al. 2018). The Consensus‐based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist provides a rigorous and structured methodology for this purpose (Terwee et al. 2018).

The present systematic review aims to identify the existing instruments designed to measure Family Focused Care, with a particular emphasis on their psychometric properties. By synthesising current evidence, this review seeks to provide a comprehensive overview of the tools available and their validity and reliability, contributing to the advancement of family care in healthcare.

1.1. Aims

This systematic review aimed to identify, appraise and describe the characteristics and measurement properties of instruments assessing Family Focused Care in nursing clinical practice. Thus, the research questions were as follows: (1) what instruments exist for measuring Family Focused Care? (2) What are the characteristics and psychometric properties of the instruments? (3) What is the quality of the instruments?

2. Methods

2.1. Design

A psychometric systematic review was carried out according to the protocol for systematic reviews of measurement properties recommended by the COnsensus‐based Standards for the selection of health Measurement INstruments (COSMIN) panel (Mokkink et al. 2024) and following the recommendations in Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) (Page et al. 2021). Modified Grading of Recommendations, Assessment, Development and Evaluation was also used to rate the best available evidence (GRADE) (Prinsen et al. 2018). This systematic review has been registered at the International Prospective Register of Systematic Reviews (PROSPERO: CRD42022315249).

2.2. Search Strategy

Initially, a preliminary search was carried out to identify key terms and index terms in the PubMed‐MEDLINE and CINAHL databases. This also helped to ensure that no other reviews were conducted with the same aim.

The Medline (PubMed), CINAHL and COCHRANE databases and the platforms Web of Science and SCOPUS were systematically searched from their time of inception to September 2024. The key terms used in the search strategy and adapted to each database were as follows: instrument OR questionnaire OR tool OR scale AND Family Focused Care OR family nursing AND clinical practice OR care AND nurs*. No language restrictions were included in the search.

The search strategy combined search terms (index and free text) with a sensitive filter to identify studies on the measurement properties of instruments (Terwee et al. 2018). This filter had a sensitivity of 97.4% and a specificity of 75.0% (See Appendix S1).

The reference lists of all included articles were searched to identify additional articles, and the names of the retrieved instruments were used as the search terms for further searches.

Articles were imported to COVIDENCE (Covidence systematic review software 2024), a management, screening, and data extraction tool for reviewers. Summaries of the search in each database were printed to ensure data capture of all research records. Furthermore, the head investigator created a repository (via Google Drive) after the screening with all the included studies with access to all the authors.

2.3. Inclusion and Exclusion Criteria

The inclusion criteria were as follows:

• –Type of participants: Samples that include nursing professionals and/or families.
• –Type of outcome: Instruments assessing Family Focused Care.
• –Type of study: Studies reporting the development of an instrument to measure any dimension of Family Focused Care, which evaluated at least one psychometric property from the COSMIN checklist.
• –Type of instruments: Self‐reported instruments, filled autonomously by nurses or family patients.

The exclusion criteria were as follows:

• –Studies using only qualitative methods to assess the construct.
• –Grey literature (editorials, conference abstracts, doctoral theses, dissertations, reviews and unpublished original validation studies).

2.4. Screening

Two independent reviewers conducted the initial screening of titles and abstracts based on the inclusion and exclusion criteria. The reviewers used a standardised form to categorise papers into three outcomes: ‘include’, ‘reject’ or ‘uncertain’. For papers categorised as ‘uncertain’ or where there was disagreement between reviewers, a discussion was held to reach consensus. If agreement could not be reached, a third reviewer was consulted to make the final decision. The initial screening of titles and abstracts was based on predefined inclusion and exclusion criteria. Papers that passed this stage proceeded to full‐text review, again conducted independently by both reviewers. The same categorisation process was applied at this stage.

2.5. Search Outcomes

The search strategy identified 6094 papers. After duplicates were removed, 3783 records were considered eligible for the review and were screened by titles and abstracts. Of these, 198 potentially answered the objective of the review. After the full texts were read, 159 articles were discarded. Therefore, 39 articles met the inclusion criteria, and eight additional articles were identified during the screening of the references. Finally, 47 papers were included in the systematic review.

Figure 1 includes information about the screening process based on the PRISMA statement and the reasons for the exclusion of studies.

FIGURE 1.

Details of the literature search and study selection. Modified PRISMA flow diagram. [Colour figure can be viewed at wileyonlinelibrary.com]

2.6. Quality Appraisal

2.6.1. Quality Assessment of the Included Studies

The methodological quality of single studies on measurement property was assessed using the COSMIN Risk of Bias checklist, developed to determine if a study on measurement properties of a self‐reported instrument meets methodological quality standards (Mokkink et al. 2024).

The COSMIN Risk of Bias Checklist consists of 10 boxes compromising 4–35 items, each box provides a score for the quality of a measurement property: (i) instrument development; (ii) content validity; (iii) structural validity; (iv) internal consistency; (v) cross‐cultural validity/measurement invariance; (vi) reliability; (vii) measurement error; (viii) criterion validity; (ix) hypotheses testing for construct validity; and (x) responsiveness (Mokkink et al. 2024). The content evaluated in each box was rated as ‘very good’, ‘adequate’, ‘doubtful’ or ‘inadequate’.

Every property was rated following the strategy of recommendation of “worst score counts” (Prinsen et al. 2018). Each property box was scored with the same value as the worst rated item.

If any property was not reported in any study, the property box was removed from the table.

This assessment was carried out by two independent reviewers; in case of disagreement, a third reviewer was consulted, and the assessment was conducted again. The assessment from the third reviewer was then the assessment that was used.

2.6.2. Quality Assessment of the Instruments

Results from each single study on a measurement property were rated against the updated criteria for good measurement properties (Prinsen et al. 2018; Mokkink et al. 2024). Each result was rated as sufficient (+), insufficient (−) and indeterminate (?) (Mokkink et al. 2024) (Appendix S2). This process was carried out by two independent reviewers; any disagreement was resolved through consulting a third reviewer who had the final say about the rating of the result.

2.6.3. Quality Summary of Evidence and Overall Grade of Evidence Quality

The quality of evidence was scored out of nine points based on the modified GRADE approach. This approach is used to downgrade the quality of a body of evidence when considering the credibility of the results, which is based on four factors: (i) risk of bias; (ii) inconsistency; (iii) imprecision; and (iv) indirectness (Prinsen et al. 2018) (Appendix S3).

2.7. Data Abstraction

Data extraction was carried out by two independent reviewers to avoid missing relevant information. A predesigned table was used, including name of the measuring tool, characteristics, authors’ year, study aim, sample size, country and setting.

2.8. Synthesis

Evidence was summarised per measurement property per instrument in a summary of findings. Each result was rated as: strong positive/negative evidence (+++/−−−), moderate positive/negative evidence (++/−−), weak positive/negative evidence (+/−), inconsistent (±) and indeterminate (?) based on the number of studies, their methodological quality and the quality and consistency of the results (Mokkink et al. 2024). This rating was carried out by two independent reviewers, and any differences were resolved through face‐to‐face discussion with a third reviewer until results were agreed upon by all members.

3. Results

3.1. Description of the Instruments and Studies

A total of 47 studies were included in this systematic review reporting on 15 instruments used to assess Family Focused Care in clinical practice (Table 1).

TABLE 1.

Included studies characteristics.

Name of the tool	Construct of the scale	Instrument characteristics	User Group	Authors‐year	Study aim	Sample size	Country	Setting
Advancing family centred new‐born intensive care: a self‐assessment inventory (AFCNBIC)	Extent to which NICUs implement and promote family centred care practices	10 subscales a 98 items and 82 sub‐items 5‐point Likert scale from 1 (not at all) to 5 (very well) Score 98–490 + 5 open‐ended questions at the end	Professionals (Nurses)	Dall'Oglio et al. (2019)	Explore family centred care practices and describe areas for improvement	46 level III NICUS nurses with NICU staff together	Italy	NICU
Family Centred Care Questionnaire (FCCQ)	Perception and practice of family centred care in healthcare settings	9 subscales 55 items 5‐point Likert scale from 1 (strongly disagree) to 5 (strongly agree). Score 55–257 Subscales: Family is a constant, collaboration, individuality, sharing information, parent‐to‐parent, developmental needs, emotional/financial, hospital systems design and staff support	Professionals (Nurses)	Bruce and Ritchie (1997)	Examine nurse's perceptions and which elements of family centred care are currently part of their practice	124 nurses	Canada	Child hospital
Family Centred Care Questionnaire Revised (FCCQ‐R)		9 subscales 45 items 5‐point Likert scale from 1 (strongly disagree) to 5 (strongly agree) Score 45–225 Same subscales as FCCQ	Professionals	Bruce et al. (2002)	Explore health professionals' perceptions and practices of the FCC extent	483 health professionals	Canada	Hospital
				Coyne et al. (2013)	Investigate the practices and perceptions of nurses towards FCC	250 paediatric nurses	Ireland	Paediatric units in paediatric and general hospitals
				Alabdulaziz et al. (2017)	Explore family centred care in the Saudi context from the paediatric nurse's perspectives	234 paediatric nurses	Saudi Arabia	Hospital
				Dall'Oglio et al. (2018)	Explore the extent to which Family centred Care principles are currently applied in clinical practice	469 healthcare providers	Italy	Paediatric hospital
				Matziou et al. (2018)	Assess nurses' perceptions of family centred care and how they applied the family centred model of care in everyday practice	183 paediatric nurses	Greece	Paediatric hospital
Family Centred Care Questionnaire Revised in Neonatal Intensive Care Unit (FCCQ‐R@it‐NICU)	Perception and practice of family centred care in NICU	45 items including the domains: family as the constant of the child's life, collaboration between parents and health professionals, recognise family individuality, sare complete information, understand the developmental needs of the child, encourage parent‐to‐parent support, provide emotional and financial support, assuring that the healthcare delivery system responds to family needs, and provide emotional support to staff	Professionals	Dall'Oglio et al. (2022)	Adaptation and validation of the NICU version of the FCCQ‐R	921 NICU professionals (registered nurses, physicians, therapists, and psychologists)	Italy	NICU
Family Centred Care Survey for Adults Intensive Care Unit (FCCS‐AICU)	Perception and experience of family centred care among family members of adult ICU patients	3 subscales: respect, collaboration, support (Mitchell et al. 2009) 20 items 4‐point Likert scale. Score 20–80 In the study of Wang et al. (2016) the scales information and empowerment where added	Family	Mitchell et al. (2009)	Evaluate the effects of Family centred care provided by critical nurses	174 family members of patients in critical care units	Australia	ICU
				Wang et al. (2016)	Develop a family centred care survey for Chinese adult intensive care units and establish the survey's psychometrics properties	249 family members of patients in AICU	China	AICU
Family Centred Care Scale for Paediatric Acute Care Nursing (FCCS‐PAC)	Parent's experience of nursing care that embodies the core principles of family centred care during their child's hospitalisation.	Scale with 7 items used to measure the degree of nurse parent mutuality experienced by parents 5‐point Likert scale. Score 7–35	Family	Curley et al. (2013)	Describe the development and initial psychometric testing of the Family Centred Care Scale	565 parents a 20 items scale and 454 a 7 items scale	United States	Hospital
Family Centred Care Scale in Intensive Care Unit (FCCS‐ICU)	Perception and experience of family centred care among family members of ICU patients	The tool consists of 5 subscales (dignity, receiving information, support, family empowerment and access to physician) 4‐point Likert scale	Family	Jafarpoor et al. (2020)	Develop and test the psychometric properties of a tool measuring FCC in ICUs	204 family members for factor analysis and 203 for confirmatory factor analysis	Iran	ICU
Family Centred Scale in Neonatal Intensive Care Unit (FCCS‐NICU)	Perception and experience of family centred care in the NICU setting	Scale of 29 items and 4 subscales (Dignity and Respect, Information Sharing, Participation to Care, and Collaboration with family) 5‐point Likert scale	Family	Akkaş and Geçkil (2023)	Develop the scale and test its validity and reliability	484 mothers of neonates hospitalised in the NICU	Turkey	NICU
Family Centred Practices Checklist (FCPC).	Extent to which practitioners engage in family centred helpgiving practices when working with families	2 subscales 17 items 4‐point Likert scale from 1 (yes) to 4 (not applicable, no opportunity to observe) Score 17–68 Scales: Relational practice and participatory practice	Professionals	Emmamally and Brysiewicz (2018)	Describe the adherence of emergency healthcare professionals to family centred practices	77 health care professionals, 70 of them nurses	South Africa	Emergency department
Family‐Focused Mental Health Practice Questionnaire (FFMHQ)	Extent and quality of family focused practice among mental health and social care professionals, particularly in the context of supporting families where a parent has a mental illness	16 subscales a 45 items 7‐point Likert Scale from 1 (strongly disagree) to 7 (strongly agree) Score 45–315 Factors: parenting support, referring family members to services and collaboration with other professionals	Professionals	Maybery et al. (2012)	Development of the questionnaire	307 adult mental health workers	Australia	Mental health services
				Leonard et al. (2018)	Explore the psychometric properties of the instrument	230 home visitors	United Kingdom	Home visiting services
Family Nursing Practice Scale (FNPS)	Self‐perceived competence, knowledge, confidence, and attitudes of nurses regarding their family nursing practice	2 subscales 10 items 5‐point Likert scale from 1 (high) to 5 (low). Score 10–50. Subscales: the practice appraisal and nurse‐family relationship. + 3 open questions about family nursing practices at the end	Professionals (Nurses)	Simpson and Tarrant (2006)	Development and testing of the FNPS	140 psychiatric nurses	China	Psychiatric hospital
				Toyama et al. (2017)	Development of a scale (FNPS) for Public Health Nurses	754 public health nurses	Japan	Maternal and child health divisions
				Naef et al. (2021)	Cross‐cultural adaptation and psychometric testing of the FNPS German version	317 hospital nurses	Switzerland	Hospital
				Rodrigues et al. (2021)	Cross‐cultural adaptation and psychometric testing of the FNPS Portuguese version	144 hospital nurses	Brazil
Iceland Family Perceived Support Questionnaire (ICE‐FPSQ)	Perceived support that family members receive from healthcare professionals when a family member is experiencing illness or hospitalisation	2 subscales 14 items 5‐point Likert‐type scale rated from 1 to 5 (“almost never,” “rarely,” “sometimes,” “often,” and “almost alway.”) Score 14–70 points Subscales: cognitive support and emotional support	Family	Sveinbjarnardottir et al. (2012)	Describe the development and psychometric testing of the instrument	415 adult family members of patients at a University Hospital, with variety of different illness diagnoses	Iceland	Hospital
				Eggenberger and Sanders (2016)	Examine the influence of an educational intervention	35 family members	United States	ICU
				Bruce et al. (2016)	Translate and test the psychometric properties of the Swedish version	97 parents of children with congenital heart defects	Sweden	Cardiac outpatient clinics
				Dieperink et al. (2018)	Compare family functioning and perceptions of support from nurses	232 participants (139 patients and 93 family members)	Denmark and Australia	Hospital oncology units
				Konradsen et al. (2018)	Translate the instrument into Danish and test its validity and reliability	70 patients	Denmark	Hospital
				Lemos et al. (2023)	Analyse the psychometric properties of the Portuguese translation of the ICE‐FPSQ	237 Parents of children/adolescents with chronic conditions	Portugal	Outpatient clinics and paediatric hospitals
				Freudiger et al. (2024)	Translate the instrument into German and test its validity and reliability	77 family members of ICU patients	Switzerland	ICU
Measure of Processes of Care (MPOC)	Parent's and professional's perceptions of the extent to which the health services they and their children receive are family centred	5 subscales 20 items 7‐point Likert scale from 1 (not at all) to 7 (to a very great extent) Score 20–140 Subscales: Respectful and supportive care, Enabling and partnership, coordinated and comprehensive care, providing specific information about the child and providing general information	Family	King et al. (2004)	Development of the Measure of Processes of Care – 20 items	653 parents of children with primarily neurodevelopmental disorders	Canada	Children rehabilitation centres
				Siebes et al. (2007)	Assessment of the reliability and validity of the 20‐item version of the Dutch Measure of Processes of Care (MPOC‐20)	405 mothers and 22 fathers of children aged 1–18 years	The Netherlands	Paediatric rehabilitation centres
				Klassen et al. (2009)	Comprehensive evaluation of the psychometric properties of the MPOC‐20	411 parents of children undergoing treatment for cancer	Canada	Paediatric oncology centres
				Saloojee et al. (2009)	Establish to what extent the MPOC‐20 needed to be adapted for the South African Settings	267 caregivers of children between 1 and 18 years diagnosed with cerebral palsy	South Africa	Hospital paediatric rehabilitation services
				Bellin et al. (2011)	Cross‐sectional research to compare parent and health care professional perspectives on the degree to which family centred care is being provided	93 parents of children with special health care needs and 43 health care providers	United States	Paediatric hospital
				Himuro et al. (2013)	Translation, adaptation and validation of the MPOC‐56 and −20	261 families with children receiving rehabilitation services	Japan	Children rehabilitation centre
				Jansen et al. (2014)	Validation of the Dutch Measure of Processes of Care for Service Providers of children with intellectual disabilities (MPOC‐SP‐PIMD)	105 professionals working with people with intellectual disabilities. Including support staff, therapists, physicians, psychologists and nurses	The Netherlands
				Himuro et al. (2015)	Examine the validity and reliability of the Measure of Processes of Care for Service Providers (MPOC‐SP) for multidisciplinary teams in neonatal intensive care units	83 multidisciplinary team members	Japan	Perinatal medical centres
				Crespo et al. (2016)	Identify the direct and indirect associations, through caregiving burden, between parents, FCC and quality of life (QoL) and life satisfaction	204 parents of children diagnosed with cancer	Portugal	Paediatric hospital services
				Gafni Lachter et al. (2019)	Evaluate the sensitivity of the service provider version (MPOC‐SP) and MPOC confidence (MPOC‐Con)	24 healthcare providers	Israel
				Antunes et al. (2020)	Translation, cross‐cultural adaptation and reliability of the Brazilian versions of the Measure of Processes of Care‐20 (MPOC‐20) and Measure of Processes of Care‐Service Providers (MPOC‐SP)	30 parents and 30 rehabilitation professionals	Brazil
Nursing Parents Support Tool (NPST)	Parent's perception of the support provided by nurses during their child's hospitalisation	4 subscales 21 items 5‐point Likert scale from 1 (almost never) to 5 (always) Score 21–105 Subscales: emotional, informational, appraisal and instrumental support	Family	Miles et al. (1999)	Development of the Nursing Parents Support Tool	108 parents of medically fragile infants hospitalised	United States	Medical centre
				Turan et al. (2016)	Determine the psychometric properties of the Turkish version of the NPST	108 mothers of premature babies hospitalised	Turkey	NICU
				Aftyka et al. (2017)	Cultural adaptation and validation of the instrument and initial assessment of parent's perception of nursing support	195 parents of children hospitalised	Poland	Hospital paediatric wards
				Mariano et al. (2022)	Determine the perceived nurse support among mothers of premature infants and translation of the instrument into Arabic	71 mothers of premature children	Qatar	NICU
Perception of Family Centred Care Staff and Parents questionnaire (PFCC‐S, PFCC‐P)	Perceptions of family centred care (FCC) practices in paediatric hospital settings	20 items 3 subscales 4‐point Likert scale from 1 to 4 (never, sometimes, usually and always, respectively) Score 20–80 Subscales: respect, collaboration and support items	Family and professionals	Shields and Tanner (2004)	Develop and trial a tool to compare parents and staff's perceptions of FCC in inpatients and outpatients, acute and chronic admissions, short‐term and long‐term hospitalisations	50 parents and 50 paediatric staff	Australia	Paediatric hospital
				Silva et al. (2015)	To assess the cross‐cultural adaptation to Brazilian Portuguese of PFCC‐S and PFCC‐P	100 parents of hospitalised children and 100 professionals from paediatric units.	Brazil	Paediatric hospital
				Vasli (2018)	Translation, cross‐cultural adaptation, and psychometric testing of the captioning of Family Centred Care‐Staff (PFCC‐S) and Perception of Family Centred Care‐Parents (PFCC‐P) questionnaires for use in paediatric nursing in Iran	For confirmatory analysis 228 nurses and 228 mothers were included. For reliability 20 nurses and 20 mothers were included	Iran	Paediatric hospital wards
				Vetcho et al. (2022)	Evaluate FCC innovations to improve respect, collaboration and support in NICU	185 parents and 20 health care professionals	Thailand	NICU
Self‐Assessment Inventory tool	Implementation of family centred care principles in emergency settings	7 subscales Each item is answered with yes or not Subscales: Vision, mission and philosophy of care, family participation in care, family support, information and decision‐making, service co‐ordination and continuity, personnel practices and training, and environment and design, evaluation/continuous quality improvement, and community partnerships	Professionals (nurses)	Almaze and De Beer (2017)	Describe Patient and Family centred care practices of emergency nurses	60 emergency nurses were included (5 of them in the pilot testing)	South Africa	Emergency departments

Abbreviations: AICU, adult intensive care unit; FCC, family centred care; ICU, intensive care unit; NICU, neonatal intensive care unit.

^a Subscales information is not available in the studies.

In terms of geographical region, 18 of the studies were conducted in Europe, 13 in Asia, 11 in America, three in Africa and three in Australia.

All instruments were reported in more than one study except the following: Advancing Family Centred New‐Born Intensive Care (AFCNBIC), Family Centred Care Questionnaire Revised in Neonatal Intensive Care Unit (FCCS‐R@ait‐NICU), Family Centred Care Scale for Paediatric Acute Care Nursing (FCCS‐PAC), Family Centred Care Scale in Intensive Care Units (FCCS‐ICU), Family Centred Care Scale in Neonatal Intensive Care Unit (FCCS‐NICU), Family Centred Practices Checklist (FCPC) and Self‐Assessment Inventory Tool (SAIT).

Seven instruments were developed and used in the paediatric population [AFCNBIC, FCCQ(−R), FCCQ‐R@ait‐NICU, FCCS‐NICU, FCCS‐PAC, Nursing Parents Support Tool (NPST) and Perception of Family Centred Care Staff and Parents questionnaire (PFCC‐P/S)], six in the adult population [FCCS‐ICU, Family Centred Care Survey for Adults Intensive Care Unit (FCCS‐AICU), FCPC, Family Focused Mental Health Practice Questionnaire (FFMHQ), Family Nursing Practice Scale (FNPS) and SAIT] and two in both the paediatric and adult populations [Iceland Family Perceived Support Questionnaire (ICE‐FPSQ) and Measure of Processes of Care (MPOC)].

In relation to the respondents, seven instruments were intended to measure Family Focused Care from the perspective of health care professionals [AFCNBIC, FCCQ, FCCQ‐R@ait‐NICU, FCPC, FFMHQ, FNPS and SAIT], six from the perspective of families [FCCS‐AICU, FCCS‐ICU, FCCS‐NICU, FCCS‐PAC, ICE‐FPSQ and NPST], and two from both health care professionals and families perspective [PFCC‐P/S and MPOC].

In addition to this, the instruments were composed of a wide range of items, from 20 to 95 items, and the number of subscales ranged from 3 to 30. Most of the instruments (n = 12) used a Likert scale to assess Family Focused Care but with different score ranges. Seven instruments used a 5‐point Likert scale, four a 4‐point, two a 7‐point, and one a 3‐point Likert scale. The only instrument that used another response format was the SAIT, which is answered with “yes” or “no”.

Finally, regarding the theoretical foundation of the instruments: the Family System Nursing model (Wright and Leahey 2000, 2013) was used to develop theFNPS, ICE‐FPSQ, and MPOC; the FCCQ was designed based on the Family Centred Care model proposed by Shelton et al. (1987); the NPST was based on House's Nurse Parent Support Model (House 1981); and finally, the PFCC‐P/S was developed based on the work of Hutchfield (1999) and Galvin et al. (2000), a qualitative study identifying themes associated with Family Centred Care and a study exploring families attitudes respectively. For the remaining instruments, there was no information about the theoretical framework that underpinned their development.

3.2. Methodological Quality of Studies and Quality of Results Reported With Measurement Instrument Properties

The methodological quality of each study and the results reported with measurement instrument properties are presented in Table 2. Ten of the 11 psychometric properties identified by COSMIN were evaluated for the included tools. Responsiveness was assessed only in two instruments: MPOC (Crespo et al. 2016; Gafni Lachter et al. 2019; Saloojee et al. 2009; Siebes et al. 2007) and PFCC‐P/S (Vetcho et al. 2022). Measurement error was not assessed in any of the included studies, so this property was omitted from the table.

TABLE 2.

Methodological quality of studies and quality of results reported with measurement instrument properties (COSMIN Risk of Bias Checklist).

Instrument	Article	PROM development	Content validity	Structural validity		Internal consistency		Cross cultural Validity/Measurement invariance		Reliability		Criterion validity		Hypothesis testing for construct validity		Responsiveness
		MQ	MQ	MQ	RQ	MQ	RQ	MQ	RQ	MQ	RQ	MQ	RQ	MQ	RQ	MQ	RQ
AFCNBIC	Dall'Oglio et al. (2019)					V	+	V	+
FCCQ‐R	Bruce and Ritchie (1997)	A	D			A	−			A	−			A	+
	Bruce et al. (2002)					V	+			A	+
	Coyne et al. (2013)					V	−			V	−
	Alabdulaziz et al. (2017)					V	−			A	−
	Dall'Oglio et al. (2018)					V	−	V	−
	Matziou et al. (2018)					V	+	A	−
FCCQ‐R@it‐NICU	Dall'Oglio et al. (2022)					V	+
FCCS‐AICU	Mitchell et al. (2009)					V	+
	Wang et al. (2016)		I	A	+	V	−	V	+			V	−	A	+
FCCS‐PAC	Curley et al. (2013)	A	I	A	+	V	+
FCCS‐ICU	Jafarpoor et al. (2020)	V	V	V	+	V	+			V	+
FCCS‐NICU	Akkaş and Geçkil (2023)	V	V	V	+	V	+			V	−
FCPC	Emmamally and Brysiewicz (2018)		I			A	+
FFMHQ	Maybery et al. (2012)	A	A			V	−
	Leonard et al. (2018)		A	A	+	V	+			D	?
FNPS	Simpson and Tarrant (2006)	V	V	V	+	V	+	A	+	A	+
	Toyama et al. (2017)		A	V	+	A	+					V	−	V	+
	Naef et al. (2021)			V	+	V	+	+	+					V	+
	Rodrigues et al. (2021)		A	A	−	V	+	+	+	A	+
ICE‐FPSQ	Sveinbjarnardottir et al. (2012)	A	A	V	+	V	+	V	+	A	+			V	+
	Eggenberger and Sanders (2016)					V	+							V	+
	Bruce et al. (2016)		V	V	+	V	+	A	+	V	+
	Dieperink et al. (2018)					V	+	A	+
	Konradsen et al. (2018)		A	V	−	V	+	A	+	V	+
	Lemos et al. (2023)			V	+	V	+			V	+
	Freudiger et al. (2024)		A	V	+	V	+	A	+			V	+
MPOC	King et al. (2004)	A				V	+					V	−	V	+
	Siebes et al. (2007)					V	+			V	+	V	−	V	+	V	+
	Klassen et al. (2009)			A	?	V	+			V	+
	Saloojee et al. (2009)			V	?	V	−	A	+	V	−			A	+	A	+
	Bellin et al. (2011)					V	−							A	+
	Himuro et al. (2013)		A	V	+	V	+	A	+	A	+
	Jansen et al. (2014)			A	?	V	−			A	+
	Himuro et al. (2015)		A	V	?	V	+	D	?	V	−
	Crespo et al. (2016)					V	+							A	+	A	+
	Gafni Lachter et al. (2019)					A	+							A	+	A	+
	Antunes et al. (2020)					V	−	V	+	V	−
NPST	Miles et al. (1999)	A	A	A	+	V	+					V	+
	Turan et al. (2016)		A	A	+	V	+	V	+
	Aftyka et al. (2017)					V	+	A	+
	Mariano et al. (2022)					V	+	A	+			V	−
PFCC‐S/ PFCC‐P	Shields and Tanner (2004)	V	V			V	+
	Silva et al. (2015)		A			V	+	A	+	V	+
	Vasli (2018)		V	V	+	V	+	V	+	V	+
	Vetcho et al. (2022)					V	−	A	+					V	+	A	+
SAIT	Almaze and De Beer (2017)		I			V	−			A	+

Note: Measurement error property box was omitted in the table because it was not evaluated in any study. See Appendix S4: Methodological quality of studies and quality of results reported with measurement instrument properties (COSMIN Risk of Bias Checklist). MQ: Methodological Quality of the Study. RQ: Quality of the Result Rated. MQ: Very good (V), Adequate (A), Doubtful (D), Inadequate (I). RQ: Sufficient (+), Insufficient (−), indeterminate.

Abbreviations: AFCNBIC, Advancing Family Centred New‐Born Intensive Care; FCCQ‐R, Family Centred Care Questionnaire (Revised); FCCQ‐R@it‐NICU Family Centred Care Questionnaire Revised in Neonatal Intensive Care Unit; FCCS‐AICU, Family Centred Care Survey for Adults Intensive Care Unit; FCCS‐ICU, Family Centred Care Scale in Intensive Care Units; FCCS‐NICU, Family centred Care Scale in Neonatal Intensive Care Unit; FCCS‐PAC, Family Centred Care Scale for Paediatric Acute Care Nursing; FCPC, Family Centred Practices Checklist; FFMHQ, Family Focused Mental Health Practice Questionnaire; FNPS, Family Nursing Practice Scale; ICE‐FPSQ, Iceland Family Perceived Support Questionnaire; MPOC, Measure of Processes of Care; NPST, Nursing Parents Support Tool; PFCC‐S/PFCC‐P, Perception of Family Centred Care Staff and Parents questionnaire; SAIT, Self‐Assessment Inventory tool.

3.3. Measurement Properties of the Instruments

3.3.1. PROM Development and Content Validity

Four instruments (FCCS‐ICU, FCCS‐NICU, FNPS and PFCC‐P/S) were rated as “very good” in terms of PROM development quality. Their respective studies made a clear description of the construct to be measured and tested not only the relevance but also the comprehensibility of the items (Jafarpoor et al. 2020; Akkaş and Geçkil 2023; Shields and Tanner 2004; Simpson and Tarrant 2006). Information was not provided for the tools AFCNBIC, FCPC and SAIT, so their PROM development quality has not been evaluated.

Content validity refers to the degree to which the content of a PROM is an adequate reflection of the construct to be measured (Mokkink et al. 2010; Flanagan and Beck 2025), and it is usually evaluated using the Content Validity Index (CVI). Five instruments were rated with a “very good” because the origin of the construct was clear, the development studies were performed in a sample representing target population and also obtained adequate CVI: FCCS‐ICU (CVI = 0.93) (Jafarpoor et al. 2020), FCCS‐NICU (CVI = 0.95) (Akkaş and Geçkil (2023); FNPS (CVI = 0.87–0.98) (Rodrigues et al. 2021; Simpson and Tarrant 2006; Toyama et al. 2017), ICE‐FPSQ (CVI = 0.84–1) (Bruce et al. 2016; Konradsen et al. 2018) and PFCCS‐P/S (CVI = 0.62–0.80) (Vasli 2018). The highest CVI was obtained by Bruce et al. (2016) with the ICE‐FPSQ obtaining a CVI score of 1.

3.3.2. Structural Validity

Structural validity refers to the degree to which the scores of the instruments reflect the dimensionality of the construct to be measured (Mokkink et al. 2010; Flanagan and Beck 2025). Among the 47 studies included, 27 tested structural validity involving 10 questionnaires. This property was not evaluated in the instruments AFCNBIC, FCCQ‐R@ait‐NICU, FCPC and SAIT.

Six studies performed Exploratory Factor Analysis (EFA) without confirming the structure of their factors. Those studies analysed the tools: FCCS‐AICU (adapted version of the PFCC‐P/S), FCCS‐PAC, FFMHQ, FNPS, MPOC and NPST. The methodological quality of most of these instruments was evaluated as “adequate” because they used adequate sample sizes for factorial techniques, and no important flaws in the statistical methods were found.

Confirmatory factor analysis (CFA) was done in 14 studies which were rated as “very good” because they reported adjustment indices such as the comparative fit index (CFI) or Tucker‐Lewis index (TLI) (Bruce et al. 2016; Himuro et al. 2013, 2015; Jafarpoor et al. 2020; Konradsen et al. 2018; Lemos et al. 2023; Naef et al. 2021; Saloojee et al. 2009; Simpson and Tarrant 2006; Sveinbjarnardottir et al. 2012; Toyama et al. 2017; Türker et al. 2023; Vasli 2018; Akkaş and Geçkil 2023). CFI and TLI values were over 0.95 in most of the studies being rated as ‘sufficient’. The best CFI results were obtained for the ICE‐FPSQ with a value of 1 (Bruce et al. 2016; Sveinbjarnardottir et al. 2012), the FCCS‐PAC with a CFI of 0.97–0.99 (Curley et al. 2013) and the PFCC‐S/P with a CFI of 0.90–0.96 (Vasli 2018). The ICE‐FPSQ obtained a Root Mean Square Error of Approximation of 0.12 and was rated as “inadequate” quality (Konradsen et al. 2018).

3.3.3. Internal Consistency

Internal consistency refers to the degree of interrelatedness among the items, and is often evaluated with Cronbach alphas (Mokkink et al. 2010; Flanagan and Beck 2025). All included studies assessed the internal consistency of the instruments, and only three questionnaires (FNPS, ICE‐FPSQ and NPST) obtained Cronbach Alpha's values over 0.70 in all of their studies, obtaining ‘very good’ for quality of measurement property.

3.3.4. Cross‐Cultural Validity/Measurement Invariance

Cross‐cultural validity/measurement invariance refers to the degree to which the performance of the items on a translated or culturally adapted instrument is an adequate reflection of the performance of the items of the original version (Mokkink et al. 2010; Flanagan and Beck 2025).

Twenty‐two studies evaluated cross‐cultural validity. The ICE‐FPSQ and MPOC were the most assessed tools regarding this property and were included in five (ICE‐FPSQ) and four (MPOC) studies of translation and validation. The most common methodology followed was forward and backward translations. Seven tools did not have any study assessing this property: FCCQ‐R@ait‐NICU, FCCS‐PAC, FCCS‐ICU, FCCS‐NICU, FCPC, FFMHQ and SAIT.

3.3.5. Reliability

Reliability is referred to as the degree to which the measurement is free from random error and is generally assessed with the Intraclass Correlation (ICC) or the weighted Kappa value (Mokkink et al. 2010; Flanagan and Beck 2025). Twenty‐one studies, referring to nine instruments, assessed this psychometric property.

The ICE‐FPSQ and PFCC‐P/S obtained the best reliability ratings, ranging their ICC between 0.77–0.96 and 0.79–0.93, respectively (Bruce et al. 2016; Konradsen et al. 2018; Silva et al. 2015; Vasli 2018; Lemos et al. 2023). The FCCQ‐R and MPOC presented inadequate reliability with ICC values < 0.70 in three of the four studies of the FCCQ‐R (Alabdulaziz et al. 2017; Bruce and Ritchie 1997; Coyne et al. 2013) and in three of the eight studies of the MPOC (Antunes et al. 2020; Himuro et al. 2015; Saloojee et al. 2009).

3.3.6. Criterion Validity

Criterion validity is defined as the degree to which the scores of an instrument are an adequate reflection of a ‘gold standard’ (Mokkink et al. 2010; Flanagan and Beck 2025).

Only six studies assessed the criterion validity of the instruments FCCS‐AICU, FNPS, MPOC, and NPST using other tools as ‘gold standard’ (see Appendix S4). For this process, five tools were used as ‘gold standard’: the Critical Care Family Needs Inventory (CCFNI) (Wang et al. 2016), the Practice of Breastfeeding Support Scale (PBSS) (Toyama et al. 2017), Beliefs Scale (King et al. 2004), Client Satisfaction Questionnaire (CSQ) (Siebes et al. 2007) and Stress Support Scale (SSS) (Miles et al. 1999). Only the NPST obtained values over 0.70, indicating a correlation between the instrument and the gold standard (the Stress Support Scale) (Miles et al. 1999).

3.3.7. Hypothesis Testing for Construct Validity

Hypothesis testing refers to the degree that the scores of a tool are consistent with the hypothesis raised by the investigators, assuming that the tool measures the construct of interest. This evaluation using convergence or divergence validity was carried out in 13 studies, including six instruments. All studies were rated as ‘very good’ or ‘adequate’ for methodological quality because they formulated a hypothesis and used adequate statistical methods for testing the hypothesis. In the same way, all studies were rated as sufficient (+) for quality of measurement property, as all the results were in accordance with the proposed hypothesis.

3.3.8. Responsiveness

Responsiveness, also called ‘longitudinal validity’ refers to the degree to which an instrument is able to measure change in the construct in the right amount, avoiding under‐ or overestimating the real change (Mokkink et al. 2010; Mokkink et al. 2021; Flanagan and Beck 2025). This property was evaluated for: MPOC and PFCC‐P/S. In the MPOC, the Pearson correlation coefficients ranged from 0.28 to 0.69 and were in accordance with the hypothesis raised in each of the studies (Crespo et al. 2016; Saloojee et al. 2009; Siebes et al. 2007). For the PFCC‐P/S, responsiveness was evaluated only considering the concordance between the result and the proposed hypothesis. Mean scores were compared between parents' results pre and postimplementation of Family Focused Care in a NICU, with at least a difference of 0.3 points in 16 of the 20 items that make up the scale (Vetcho et al. 2022).

3.4. Quality Summary of Evidence and Overall Grade of Evidence Quality

Based on the modified GRADE approach (Table 3) only the instruments FNPS and PFCC‐P/S scored 9 out of 9, meaning the higher quality of evidence.

TABLE 3.

Quality of evidence with GRADE approach.

Instrument	Risk of bias	Inconsistency	Imprecision	Indirectness	Total
AFCNBIC	1/3	2/2 a	0/2	2/2	5/9
FCCQ‐R	1/3	1/2	2/2	2/2	6/9
FCCQ‐R@it‐NICU	1/3	2/2 a	2/2	2/2	7/9
FCCS‐AICU	3/3	1/2	2/2	2/2	8/9
FCCS‐PAC	1/3	1/2	2/2	2/2	7/9
FCCS‐ICU	1/3	2/2 a	2/2	2/2	7/9
FCCS‐NICU	2/3	2/2 a	2/2	2/2	8/9
FCPC	1/3	2/2 a	1/2	2/2	6/9
FFMHQ	2/3	1/2	2/2	2/2	7/9
FNPS	3/3	2/2	2/2	2/2	9/9
ICE‐FPSQ	3/3	2/2	1/2	2/2	8/9
MPOC	2/3	1/2	1/2	2/2	6/9
NPST	3/3	2/2	1/2	2/2	8/9
PFCC‐S/PFCC‐P	3/3	2/2	2/2	2/2	9/9
SAIT	1/3	2/2 a	1/2	2/2	6/9

Note: Higher scores indicate higher quality of the evidence according to GRADE criteria. Measurement error property box was omitted in the table because was not evaluated in any study. Results from 0 to 9. Lower scores in this scale indicates lower quality of evidence.

Abbreviations: AFCNBIC, Advancing Family Centred New‐Born Intensive Care; FCCQ‐R, Family Centred Care Questionnaire (Revised); FCCQ‐R@it‐NICU Family Centred Care Questionnaire Revised in Neonatal Intensive Care Unit; FCCS‐AICU, Family Centred Care Survey for Adults Intensive Care Unit; FCCS‐ICU, Family Centred Care Scale in Intensive Care Units; FCCS‐NICU, Family Centred Care Scale in Neonatal Intensive Care Units, FCCS‐PAC, Family Centred Care Scale for Paediatric Acute Care Nursing; FCPC, Family Centred Practices Checklist; FFMHQ, family Focused Mental Health Practice Questionnaire; FNPS, Family Nursing Practice Scale; ICE‐FPSQ, Iceland Family Perceived Support Questionnaire; MPOC, Measure of Processes of Care; NPST, Nursing Parents Support Tool; PFCC‐S/PFCC‐P, Perception of Family Centred Care Staff and Parents questionnaire; SAIT, Self‐Assessment Inventory tool.

^a Inconsistency value not valid as tool was included in only one study.

Risk of bias analyses whether the quality of a study is doubtful or inadequate after assessing with COSMIN. This property was rated with the highest score to FCCS‐AICU, FNPS, ICE‐FPSQ, NPST and PFCC‐P/S meaning that no risk of bias was present in their studies. The instruments AFCNBIC, FCCQ(−R), FCCQ‐R@it‐NICU, FCCS‐PAC, FCPC and SAIT were rated as ‘very serious risk of bias’ in terms of their methodology. None of the included instruments had an ‘extremely serious risk of bias’.

Inconsistency of the evidence refers to the concordance between the results of the studies. Serious inconsistency was found in the studies of the following instruments: FCCQ(−R), FCCS‐AICU (adapted version of the PFCC‐P/S), FCCS‐PAC, FFMHQ and MPOC. No tool presented a ‘very serious’ inconsistency. On the other hand, the most consistent instruments were FNPS, ICE‐FPSQ, NPST and PFCC‐P/S.

Imprecision was mainly rated with the sample size. Eight of the included instruments had the best score with samples over 100: FCCQ‐R, FCCQ‐R@ait‐NICU, FCCS‐PAC, FCCS‐ICU, FCCS‐NICU, FFMHQ, FNPS and PFCC‐P/S. The instrument AFCNBIC obtained the lowest score, meaning higher values of imprecision because its sample size was under 50 (Dall'Oglio et al. 2019).

Finally, indirectedness refers to the population or context. The score was downgraded if the study population or context differed from the interest of the systematic review. All included instruments obtained the highest value because all populations and contexts were the same as the review population of interest.

3.5. Summary of Evidence

Evidence was summarised in Table 4 based on the number of studies, their methodological quality and the quality and consistency of the results (Terwee et al. 2009, 2018). The ICE‐FPSQ and the PFCC‐P/S obtained positive ratings for all the psychometric properties evaluated. The instrument for which more psychometric properties were evaluated was the MPOC, and the least was the FCPC, being evaluated only for internal consistency.

TABLE 4.

Summary of findings.

Instrument	Structural validity	Internal consistency	Cross‐cultural validity/measurement invariance	Reliability	Hypotheses testing	Responsiveness
AFCNBIC	—	++	+	—	—	—
FCCQ‐R	±	?	+	?	+	—
FCCQ‐R@it‐NICU	—	+	—	—	—	—
FCCS‐AICU	++	++	+	±	+	—
FCCS‐PAC	++	++	—	—	—	—
FCCS‐ICU	++	++	—	−	—	—
FCCS‐NICU	++	++	—	−	—	—
FCPC	—	++	—	—	—	—
FFMHQ	+	+	—	—	—	—
FNPS	++	+++	++	±	++	—
ICE‐FPSQ	++	+++	++	++	+	—
MPOC	±	±	++	−	?	++
NPST	+	+++	++	—	—	—
PFCC‐S/ PFCC‐P	++	++	++	++	+	+
SAIT	—	++	—	?	—	—

Note: Measurement error property box was omitted in the table because it was not evaluated in any study. +++/−−−: strong positive/negative evidence; ++/−−: moderate positive/negative evidence; ±: conflict of findings; ?: unknown evidence; —: no information available.

Abbreviations: AFCNBIC, Advancing Family Centred New‐Born Intensive Care; FCCQ‐R, Family Centred Care Questionnaire (Revised); FCCQ‐R@it‐NICU, Family Centred Care Questionnaire Revised in Neonatal Intensive Care Unit; FCCS‐AICU, Family Centred Care Survey for Adults Intensive Care Unit; FCCS‐ICU, Family Centred Care Scale in Intensive Care Units; FCCS‐PAC, Family Centred Care Scale for Paediatric Acute Care Nursing; FCPC, Family Centred Practices Checklist; FFMHQ, Family Focused Mental Health Practice Questionnaire; FNPS, Family Nursing Practice Scale; ICE‐FPSQ, Iceland Family Perceived Support Questionnaire; MPOC, Measure of Processes of Care; NPST, Nursing Parents Support Tool; PFCC‐S/PFCC‐P, Perception of Family Centred Care Staff and Parents questionnaire; SAIT, Self‐Assessment Inventory Tool.

4. Discussion

To our knowledge, this is the first systematic review aimed at identifying, appraising, and describing the characteristics and measurement properties of instruments assessing Family Focused Care in nursing clinical practice.

Forty‐eight studies were included in this review reporting on 15 instruments. Overall evidence was limited by the availability of the studies for each instrument. The psychometric testing approaches varied widely among the different studies. None of the studies tested all the nine measurement properties proposed by the COSMIN guideline (Mokkink et al. 2024) nor do they indicate that the COSMIN guide was followed for developing the instruments.

According to Mokkink et al. (2010) the development of a tool is the most crucial step to ensure adequate content validity and methodological quality. Moreover, if the content validity is doubtful, the rest of the psychometric properties may be affected. In this systematic review, the three instruments with the best GRADE results (FCC‐AICU, FNPS, and (PFCC‐P/S) are the ones that obtained a ‘very good’ score in their PROM development section of COSMIN (Akkaş and Geçkil 2023; Rodrigues et al. 2021; Jafarpoor et al. 2020; Simpson and Tarrant 2006). These values ensure that these tools measure the intended constructs, the perception of FFC provided.

Internal consistency was the most frequently evaluated measurement property, assessed in all instruments, followed by structural validity, which was assessed for all instruments except for AFCNBIC, FCCQ‐R@it‐NICU, FCPC and SAIT. Internal consistency was evaluated in most of the studies with Cronbach's alpha values greater than 0.7 for the whole instruments and for each dimension. Only two instruments obtained Cronbach's alpha values lower than 0.7 for specific dimensions. For the FCCQ‐R, the dimension ‘family is a constant’ was lower than 0.6 (Coyne et al. 2013; Dall'Oglio et al. 2018). For the MPOC, the dimensions ‘enabling and partnership’ and ‘communicating specific information’ obtained values under 0.65 (Antunes et al. 2020; Bellin et al. 2011). However, the dimension ‘communicating general information’ obtained a Cronbach's alpha of 0.91 (Bellin et al. 2011). These findings indicate that, while most instruments demonstrate strong overall reliability, careful evaluation of individual subscales is necessary, as some specific domains may require refinement to ensure consistent performance.

Structural validity was evaluated as ‘very good’ for the methodological quality of most studies. Among the instruments identified, there is a wide range of dimensions used to measure Family Focused Care. Some of these dimensions are similar among the different instruments: family–staff collaboration or relationship (FNPS, ICE‐FPSQ), the provision of information (MPOC, NPST) and emotional support (ICE‐FPSQ, MPOC). These dimensions coincide with the core elements of the FCC model stated by the Institute for Patient and Family Centred Care (2017).

The MPOC, FCCQ‐R and ICE‐FPSQ were the most assessed instruments. Whereas the AFCNBIC, FCCS‐PAC, FCCS‐ICU, FCPC and SAIT have been assessed in only a single study. Consequently, additional evaluation of the psychometric properties of these instruments is required.

According to the review results, the FNPS, ICE‐FPSQ and PFCC‐P/S instruments seem to be the most suitable measures for assessing Family Focused Care in clinical practice.

The FNPS reported data on eight of the nine psychometric properties with a minimum of ‘adequate’ ratings in their Methodological Quality of the Studies. The only property not assessed was responsiveness. Four studies analysed its psychometric properties; all of them reported Cronbach Alpha's values over 0.7 in both of its subscales: the practice appraisal and the nurse‐family relationship (Rodrigues 2021; Naef et al. 2021; Simpson and Tarrant 2006; Toyama et al. 2017). This instrument was tested in three other languages: Chinese (Simpson and Tarrant 2006), German (Naef et al. 2021) and Portuguese (Rodrigues 2021). This assessment of psychometric properties makes the FNPS a valuable tool for monitoring and improving family care, as it allows for reliable benchmarking across different settings and populations.

The ICE‐FPSQ was analysed in seven studies that reported seven psychometric properties with a minimum of ‘adequate’ ratings. In all studies, Cronbach Alpha's values were over 0.7 (Bruce et al. 2016; Dieperink et al. 2018; Eggenberger and Sanders 2016; Konradsen et al. 2018; Sveinbjarnardottir et al. 2012; Lemos et al. 2023; Freudiger et al. 2024). The instrument is composed of two subscales: cognitive support and emotional support. The only negative rating was obtained in the Quality of Result Rated of the structural validity, where in the Konradsen et al. (2018) study RMSEA value in the structural validity was 0.12 (acceptable values are < 0.6; Prinsen et al. 2018; Terwee et al. 2018). Cronbach Alpha's values for the ICE‐FPSQ ranged between 0.7 and 0.9 (Lemos et al. 2023; Konradsen et al. 2018; Sveinbjarnardottir et al. 2012). This instrument was translated and validated in five languages: Swedish (Bruce et al. 2016), Icelandic (Sveinbjarnardottir et al. 2012), Danish (Dieperink et al. 2018; Konradsen et al. 2018), Portuguese (Lemos et al. 2023) and German (Freudiger et al. 2024). The emphasis on both cognitive and emotional support highlights how the instrument can foster a comprehensive approach to family care, addressing not only informational needs but also the emotional well‐being of families, which is essential for effective Family Focused Care interventions (Bruce et al. 2016; Eggenberger and Sanders 2016).

The PFCC‐P/S developed by Shields and Tanner (2004) was analysed in four studies that reported eight psychometric properties with a minimum of ‘adequate’ ratings. Cronbach Alpha's values were over 0.7 in the four studies (Shields and Tanner 2004; Silva et al. 2015; Vasli 2018; Vetcho et al. 2022). The instrument is composed of three subscales: respect, collaboration and support. It obtained one negative rating, in the internal consistency in the study of Vetcho et al. (2022) with a Cronbach Alpha of 0.663. This instrument was translated and validated in three languages: Iranian (Vasli 2018), Brazilian Portuguese (Silva et al. 2015) and Thai (Vetcho et al. 2022).

In addition to the psychometric properties, it is important to take into account the target population when choosing the instruments. Including both professionals and families perspectives regarding Family Focused Care is a strong point not only for the measurement but also for the implementation process. Comparing both perceptions allows the professional to be aware of the differences or discrepancies between the perception of care offered by them and that received by the family, and to be able to modify their actions based on it (Foster and Whitehead 2017). In this review, only the PFCC‐P/S and the MPOC included both respondent samples.

Measures in Family Focused Care that can be used in different contexts are needed (Clay and Parsh 2016). According to the American Medical Association Journal of Ethics, Family Focused Care applies to patients of all ages and can be practiced in any health care setting and at any point in care delivery (Clay and Parsh 2016). In this regard, studies focused solely on the paediatric population continue to predominate (Kokorelias et al. 2019). In this review, 29 of the 47 included studies deal exclusively with the paediatric population, and only two instruments of the 15 analysed were used with both paediatric and adult patients (MPOC and PFCC‐P/S). Of the five instruments used exclusively in the paediatric population, only the PFCC‐P/S was adapted to be used in the adult population, changing the wording of the items for this purpose (FCCS‐AICU) (Mitchell et al. 2009). However, this version has not been validated. Also, Wang et al. (2016) used the PFCC‐P/S in the adult population, but they added two new factors, empowerment and information, and validated this new version.

Moreover, the use of standardised instruments enables comparisons in different settings and populations (Prinsen et al. 2018), supports research on impact of Family Focused interventions, and helps with the development of policies and programs aimed at enhancing family engagement in care (Clay and Parsh 2016). Ultimately, these tools are needed not only to assess current practice, but also to assess improvements, foster a culture of partnership, and improve outcomes for patients, families and nurses (Shields 2015; Kokorelias et al. 2019).

4.1. Limitations and Strengths

The evaluation of the methodological quality of the instruments was carried out following the COSMIN standards, but this process presented some challenges since none of the included studies indicated that they had considered the COSMIN guideline for the validation or development of the instruments. Even many of the instruments were developed before the COSMIN guideline was established (Mokkink et al. 2010). Therefore, it is probable that some instruments received only poor or fair scores according to the COSMIN criteria due to a lack of information provided in the studies (Mokkink et al. 2010).

COSMIN guidelines apply the ‘worst score counts’ criterion when evaluating the overall score of a psychometric property (Mokkink et al. 2010). Consequently, more emphasis is given to weaknesses in the assessment of the properties.

Despite carrying out an exhaustive systematic review by peers, without date or language limits and using five international databases, no grey literature was included. If any instrument was reported in the grey literature, it has not been included in the review. However, the instrument validation process is carried out in scientific journals, so the number of lost instruments will be minimal.

Moreover, there is a possibility that there is a publication bias and that validation studies which have obtained negative results have not been published. However, as it has been seen in this review, there are also included studies with non‐positive results.

This review also presents some strengths. It is the first systematic review of the measurement properties of instruments to measure Family Focused Care by evaluating their psychometric properties using COSMIN guidelines, PRISMA recommendations, and that analyses available evidence using GRADE guidelines. Furthermore, the entire process was carried out independently by two researchers, with a third reviewer being consulted in the case of discrepancies. In addition, one of the first steps of this review was the registration of the protocol in PROSPERO, so that the methodology has remained rigorous and has not undergone changes.

5. Conclusion

This psychometric review provides a rigorous synthesis of instruments designed to assess Family Focused Care in clinical practice. This will help researchers and clinical professionals select the best instrument available for their research or clinical practice based on the critical appraisal and comparison of the measurement properties according to a rigorous methodology.

However, there is no perfect, easily recommended instrument, and selection of the most appropriate tool depends on its purpose, scope and context. In other words, each instrument has its strengths and weaknesses. To further support informed decision‐making, it is recommended that the selection of an instrument should be guided by three key considerations: (i) the intended purpose (whether to assess the perceptions of professionals, families or both), (ii) the target population (adult, paediatric or both) and (iii) the specific clinical setting in which it will be used, such as intensive care units, hospital wards, or outpatient centres. For instance, some instruments may be more appropriate for specific populations or contexts. Providing this guidance helps ensure that the selected tool aligns with the specific needs and characteristics of the intended users.

From a methodological standpoint, the FNPS, ICE‐FPSQ and PFCC‐P/S seem to be the most suitable instrument to measure Family Focused Care in the nursing clinical practice. According to the COSMIN checklist, these are the only instruments where most of the psychometric properties have been evaluated and have obtained higher scores. Moreover, these three instruments also presented the best methodological quality according to GRADE approach. Although these instruments are the most notable, the choice by researchers and nurses of the instrument to be used must be carried out considering the research method, the population to which they are directed and the elements that most interest them to evaluate.

It is believed that this review facilities a better understanding of these tools and promote their use in further research, thus increasing the body of knowledge about the applicability of Family Focused Care in clinical practice.

Future research should focus on generating evidence about the psychometric properties of these instruments using a rigorous and structured guide, such as the COSMIN checklist criteria, and developing further adaptations of these tools in different countries and populations.

Author Contributions

Bilal Benbelkheir: conceptualisation, writing – original draft, methodology, validation. Ana Canga‐Armayor: conceptualisation, writing – original draft, validation, supervision. Cristina Alfaro‐Diaz: conceptualisation, writing – original draft, validation, supervision, methodology. Navidad Canga‐Armayor: writing – review and editing. María Pueyo‐Garrigues: writing – review and editing. Erla Kolbrun Svavarsdottir: writing – review and editing. Nuria Esandi: conceptualisation, writing – original draft, validation, supervision.

Ethics Statement

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix S1

Appendix S2

Appendix S3

Appendix S4

Appendix S5

Data Availability Statement

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