How to Involve Families in Hospital Care: Development, Content Validation, and Feasibility of a Concise Family Assessment Framework

ABSTRACT

Background

Family members play a vital role in supporting patients during hospitalization, yet their involvement is often insufficiently recognized. Existing family assessment tools are typically developed for community or long‐term care settings and are too complex or time‐intensive for hospital use. A concise and feasible assessment framework is needed to facilitate the effective involvement of family members in patient care and to support healthcare professionals in acknowledging, aligning and collaborating with families during hospitalization.

Aim

To develop, validate and evaluate the feasibility of a family assessment framework with relevance for use in hospital settings.

Methods

A four‐phase sequential study was conducted to develop and test a family assessment framework. The framework was informed by a review of existing tools, validated through a two‐round Delphi study with international experts, refined in focus groups with family members and pilot‐tested by nurses to assess feasibility.

Results

The family assessment framework includes essential discussion items at admission—such as family structure, functioning and needs—along with required professional attitudes, skills and contextual conditions. Experts and families confirmed its clarity and completeness. Nurses viewed it as a flexible, supportive conversation guide rather than a checklist. Its use enhanced recognition of caregiving roles and clarified mutual expectations. Implementation requires workflow adjustments, role definitions and attention to communication skills.

Conclusion

The validated and feasible family assessment framework structures and facilitates family involvement in hospital care through essential discussion items between patients, family members and healthcare professionals, thereby improving the quality of care.

1. Introduction

Family System Nursing (FSN) frames the family as a unit of care whose functioning directly affects patient outcomes [1]. Within this perspective, family members continuously influence one another, and changes in one member's health can affect the entire family system. Families provide informational, emotional and practical support as part of their reciprocal interactions within the system [2, 3]. Through these interactions, families contribute to improved patient outcomes. They share insights into the patient's history and preferences, support coping and decision‐making and assist with daily tasks when patients are temporarily dependent [4, 5]. Involving family members not only benefits patients but also provides families with a sense of purpose and participation [6].

Despite their important role, families often experience unmet needs during hospitalization, particularly regarding information, clarity about their role and emotional support [7, 8]. Without proper guidance, their ability to contribute meaningfully may be reduced [9, 10]. Healthcare professionals can mitigate this by actively involving and supporting family members, enabling them to participate more effectively in care [11, 12].

Within FSN, family assessment translates the theoretical concept of family functioning into clinical practice. By exploring the family's structure, relationships and available resources, assessment provides insight into how the family functions and what support may be needed to strengthen collaboration. To ensure that this supportive and collaborative potential is realized in practice, healthcare professionals need insight into the family's functioning, roles and capacities from the start of hospitalization [1]. Conducting such an assessment at hospital admission can help clarify expectations, identify strengths and reveal needs that require support.

Internationally, there is growing recognition that family carers are an essential yet under‐supported part of healthcare systems. Organizations such as the International Alliance of Carer Organizations, the Family Caregiver Alliance and Eurocarers highlight the urgent need for structured caregiver assessment to identify carers' strengths, needs and preferences for involvement [13, 14, 15]. Although several family assessment tools are available, most have been developed for community or long‐term care settings and are often too complex or time‐intensive for the acute hospital contexts [1, 16]. In busy hospital wards, where time and continuity of care are limited, these tools are rarely used in routine practice. As a consequence, important aspects of family functioning remain overlooked and opportunities for effective alignment between families and healthcare teams are missed.

Recent developments, such as the Care Partner Hospital Assessment Tool (CHAT) [17] and its dementia adaptation (D‐CHAT) [18], have advanced the recognition and support of care partners in hospital settings. These multidimensional screening tools focus on documenting care partners' contexts, preferences, well‐being, skills and available resources in order to guide education, skills training and referral processes, particularly in preparation for care during and after discharge.

The present study addresses a complementary and conceptually distinct aim. Rather than functioning as a screening or decision‐support instrument, it develops a family assessment framework grounded in the principles of Family Systems Nursing. The framework delineates the essential relational, communicative and organizational aspects that are relevant to discuss with family members at the start of hospitalization to support early acknowledgement of the family system, clarification of roles and alignment of expectations between families and healthcare professionals. In doing so, it provides a foundation for collaborative practice throughout the hospital stay across patient groups.

1.1. Aim

The aim of this study was to develop, validate and evaluate the feasibility of a concise family assessment framework with relevance for use in hospital settings.

1.2. Objective of the Framework

The framework is intended to facilitate effective family involvement in patient care and to help healthcare professionals acknowledge, align and collaborate with families.

1.3. Research Question

What are the essential components of a family assessment framework that are relevant to be addressed with family members at the start of hospitalization to enable their involvement in patient care, and what professional competencies and contextual conditions are required for effective implementation in clinical practice?

2. Methods

2.1. Design

This study was conducted in four sequential phases. In Phase 1, a review of reviews was performed to develop a preliminary version of the framework based on existing family assessment tools. In Phase 2, the essential aspects of the family assessment framework from Phase 1 were validated through an online Delphi consensus process. Subsequently, in Phase 3, family members reflected on the finalized family assessment framework from Phase 2. Finally, in Phase 4, the family assessment framework was tested by nurses in clinical practice to evaluate its feasibility. Each phase will be elaborated upon in the following sections; see Figure 1.

FIGURE 1.

Sequential phases of the study.

This study, approved by the Ethical Advisory Committee of Hanze University of Applied Sciences (heac.T2024.064), was conducted in accordance with the GUIDED guideline for reporting intervention development studies in health research [19].

2.2. Methods Phase 1: Review of Reviews

2.2.1. Design

A review of scientific literature was conducted to identify the essential aspects of a family assessment that could inform a framework relevant for hospital settings.

2.2.2. Search Methods and Inclusion Criteria

A structured search in line with rapid review guidelines [20] was performed in CINAHL and MEDLINE using the keywords ‘family assessment tool(s)’, ‘family assessment’ and ‘family assessment device’. Limits were set to peer‐reviewed, full‐text (systematic) reviews published in English between 2000 and 2024. Reviews were eligible if they addressed tools assessing family functioning or family dynamics. This approach was chosen to capture theoretically grounded family assessment frameworks that transcend specific care contexts and could be analytically examined for relevance to hospital practice.

2.2.3. Selection and Synthesis

The search identified several systematic reviews comparing available assessment tools. Given this overlap, these reviews were used as the primary data source to facilitate a structured comparison of frameworks relevant to hospital settings [12]. An overview of reviews summarized evidence from multiple sources, providing a rapid yet comprehensive understanding of different assessment tools [20]. To identify key aspects for family assessment in a hospital setting, these tools were further examined using additional literature and analysed from the framework of FSN [1]. Essential attitudes, skills and conditions required of healthcare professionals were also considered. Concepts were synthesized across sources and validated through team discussions. Findings from our previous research on family and healthcare professional perspectives [8, 21] complemented this process, helping to contextualize and validate the emerging key aspects.

2.3. Methods Phase 2: Content Validity Testing

2.3.1. Study Design

Phase 2 aimed to validate the essential concepts and items of the family assessment framework developed in Phase 1. This content validity testing was conducted using the Delphi method [22].

2.3.2. Study Setting, Sampling and Inclusion Criteria

A panel of 45 experts was recruited for this Delphi study, including physicians, nurses and researchers with demonstrated expertise in family involvement in hospital care, either through clinical practice or academic work. Physicians and nurses were selected because they are the central providers with continuous contact with patients and families during hospitalization, making their input crucial for identifying essential information at admission. Participants were strategically selected via professional networks, including ongoing research collaborations, contacts from the International Family Nursing Association and healthcare professionals trained in family nursing. Inclusion criteria required the ability to assess the relevance of items in the context of family assessment at the start of hospitalization. This approach ensured that all panel members had both theoretical and practical knowledge of family care in hospital settings. The 45 experts were recruited from five countries (the Netherlands, Belgium, Spain, Iceland and Denmark). The panel consisted predominantly of experts from the Netherlands (n = 41), with one expert each from Belgium, Spain, Iceland and Denmark.

2.3.3. Instrument and Data Collection

A Delphi survey was developed following the technique described by Lawshe [23] and included 26 items across six domains, derived from the family assessment framework developed in phase 1. Each expert received a personalized email link and rated each item on a 3‐point scale (essential, important but not essential, not necessary), specifically in the context of a routine family assessment at hospital admission [23]. Open‐ended questions allowed for additional feedback and suggestions. Anonymity was ensured, and reminders were sent after 1 week. Based on expert input, the second‐round questionnaire was refined with revised and newly proposed items.

2.3.4. Data Analysis

To assess consensus, Content Validity Ratios (CVRs) were calculated using the formula (Ne − N/2)/(N/2), where Ne is the number of experts rating the item as essential [24]. In Round 1 (n = 37), the critical CVR threshold was 0.29; in Round 2 (n = 34), it was 0.35. Only items meeting these thresholds were included in the final framework. Items falling below the threshold but accompanied by constructive feedback were revised; others were excluded.

2.4. Methods Phase 3: Reflection

2.4.1. Study Design and Framework

The third phase aimed to evaluate the relevance of the family assessment framework from the perspective of family members as end users. Focus groups were conducted following Hennink et al.'s approach, which emphasizes participant interaction to deepen reflection [25]. A guide based on the Delphi results supported the discussions, including prompts such as ‘Is this relevant to you?’ and ‘Would you expect this during a hospital stay of a family member?’ (see File S1).

2.4.2. Setting, Recruitment and Participants

Two focus groups were organized in a hospital in the north of the Netherlands to ensure accessibility and a familiar environment. Recruitment occurred via a hospital patient panel, a caregiving support platform, research network outreach and an open call for volunteers. Eligibility required experience with a hospitalized family member. Sessions were scheduled at different times (afternoon and evening) to accommodate availability. Each group included five participants and was facilitated by a moderator (S.B.) and an observer (J.W.). Discussions lasted approximately 2 h and focused on the applicability and completeness of the framework.

2.4.3. Data Collection and Analysis

Sessions were audio‐recorded and transcribed verbatim; field notes taken by the observer were used to provide context and capture non‐verbal cues. A deductive thematic analysis was conducted, guided by the framework concepts from the Delphi phase [26]. Two researchers (J.W., S.B.), both experienced in qualitative research, independently performed open coding and refined themes through iterative discussions. Codes outside the predefined framework were assessed for possible inclusion.

2.5. Methods Phase 4: Feasibility Testing

2.5.1. Study Design and Framework

The final phase evaluated the feasibility of the family assessment framework in clinical practice. A practice‐based qualitative design was applied, guided by a feasibility model focusing on clarity, usability, integration into existing practice and perceived value [27].

2.5.2. Setting, Participants and Recruitment

The study was conducted in four hospitals in the Netherlands. Eight nurses from different departments were recruited via the research group's professional network. Eligibility criteria included employment in a hospital setting and involvement in‐patient admissions. Nurses were selected if they had either completed a family conversation course or engaged in family‐centred care initiatives, ensuring motivation and competence to apply the framework during feasibility testing. To broaden participation, these nurses were encouraged to invite colleagues, following a snowball sampling strategy. The framework was initially implemented in surgical and internal medicine departments, including geriatrics.

2.5.3. Procedures and Data Collection

During a six‐week pilot, participants integrated the family assessment framework into their work processes for at least two patient admissions. A user manual accompanied the framework, emphasizing flexible use across contexts; no formal training was provided prior to implementation. Nurses assessed clarity, ease of use, workflow compatibility and overall utility (see File S2). Afterward, participants completed individual semi‐structured online interviews (±30 min) to reflect on their experiences. All interviews were conducted by J.W., recorded, and supplemented with field notes.

2.5.4. Data Analysis

Transcripts were analysed thematically using a deductive approach guided by the predefined feasibility aspects [26]. Two researchers independently coded data, focusing on perceived benefits, content suggestions, workflow integration and future implementation. Codes were refined through iterative discussions to ensure consistency and shared interpretation [28].

2.6. Ethical Considerations and Rigour Across All Phases

The study received ethical approval and informed consent, confidentiality and anonymity were ensured throughout all phases. Rigour was maintained via investigator triangulation, grounding findings in literature and participant data, team validation of emerging themes, and an audit trail documenting methodological decisions [26, 29]. Participant input was handled respectfully; only family members in focus groups received a gift voucher, informed shortly before participation, which did not influence their decision to join. Feasibility testing was conducted without disrupting care, ensuring consistent ethical standards and trustworthiness throughout the study [28].

3. Results

3.1. Results Phase 1: Review of Reviews to Develop a Family Assessment Framework

A structured database search identified 89 reviews, of which 57 were screened based on title and abstract. Ultimately, eight reviews were included as they provided an overview of various family assessment tools or devices. In addition, four books containing relevant family assessment tools were identified through supplementary searches. The selection process is illustrated in Figure 2 (flow diagram).

FIGURE 2.

Flow diagram for eligible literature identification. Adapted from: Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Licensed under CC BY 4.0. Modified to include an additional search block.

A comparative analysis of all identified family assessment tools was conducted to determine which domains are most relevant to consider for information exchange with family members at the start of a hospital admission. For each tool, the underlying concepts, subdomains or representative items were extracted and systematically compared within the framework of FSN. Synthesizing these overlapping domains resulted in three overarching concepts essential for use at hospital admission: family structure, family functioning and family needs and willingness. For a more detailed overview of the reviewed tools and extracted domains, see Files S3 and S4.

3.1.1. Development of the Family Assessment Framework

A draft framework for family assessment in hospital settings was developed based on these three key concepts, incorporating a diversity of specific items. Family structure provides insight into the composition, roles and external support systems of the family, drawing on models such as the Calgary Family Assessment Model [1]. Family functioning examines how family members interact and fulfil roles within the family system. Tools like the Family Assessment Device (FAD) highlight key domains such as communication, role distribution and overall functioning [30]. Family needs and willingness focus on the support families require, their ability to adapt, and their role in patient care during hospitalization [1].

In addition to the substantive elements, the framework incorporates essential professional attitudes and skills (e.g., acknowledging patient preferences for family involvement, actively engaging families and communicating clearly and empathetically) and organizational conditions (e.g., systematic documentation, training and sufficient time allocation). The draft framework is provided as File S5.

3.2. Results Phase 2: Content Validity Testing of the Family Assessment Framework

The family assessment framework developed in phase 2 was validated by an expert panel using the Delphi method in two rounds. In both rounds, 45 experts were invited to participate. In the first round, 37 experts responded (response rate: 82%), and in the second round, 34 experts responded (response rate: 76%). The experts were healthcare professionals and/or researchers working in various specialties, including intensive care, paediatrics, internal medicine, geriatric medicine, oncology and surgery. They had diverse experiences with hospital care and family involvement (see Table 1).

TABLE 1.

Characteristics of the Delphi experts.

	Round 1 (N = 37)		Round 2 (N = 34)
	N	Percent (%)	N	Percent (%)
Age (years)
21–40	16	43.2	15	44.1
41–60	18	48.7	17	50.0
61–80	3	8.1	2	5.9
Sex
Male	5	13.5	5	14.7
Female	32	86.5	29	85.3
Country of residence
Netherlands	34		30
Belgium	1		1
Iceland	1		1
Spain	1		1
Denmark	0		1
Current position (multiple answers possible)
Physician	10		10
Nurse	17		15
Researcher	12		9
Experience in hospital setting (years)
0–4	3	8.1	3	8.8
5–9	7	18.9	8	23.5
10–14	5	13.5	4	11.8
15–19	10	27.0	5	14.7
20–24	4	10.8	5	14.7
25–29	4	10.8	6	17.7
30+	4	10.8	3	8.8
Experience regarding family involvement (multiple answers possible)
Scientific research	15		13
Practical experience	33		32
Taken training (past 5 years)	7		8
Provided training	11		10

In the first round, the Delphi panel validated the framework developed from the literature, which consisted of five concepts and 26 items. Based on this round, several new or revised items were presented in the second round (Table 2). Table 2 presents the first and second round combined for clarity.

TABLE 2.

Delphi first round (n = 37) and Delphi second round (n = 34).

Delphi first round (n = 37)	Essential			Delphi second round (n = 34)	Essential
Attitudes/skills of healthcare professionals	%	N	CVR a	Attitudes/skills of healthcare professionals	%	N	CVR b
Healthcare professionals consider the preferences, wishes and values of the patient when involving family members.	91.9	34	0.84	Healthcare professionals assess the needs and expectations of family members.	79.4	27	0.59
Healthcare professionals encourage patients to bring family members to the hospital so that family can be involved in care and the decision‐making process.	64.8	24	0.30	Healthcare professionals evaluate potential risks, such as overload, that may affect a family member's role in care.	76.5	26	0.53
Healthcare professionals ask questions to gain insight into the perspectives of family members on the patient's care and situation.	81.1	30	0.62
Healthcare professionals listen attentively to what family members say and respond to their concerns, questions and suggestions.	91.9	34	0.84
Healthcare professionals use language and explanations that align with the language proficiency and experiences of family members.	94.6	35	0.89
Healthcare professionals verify, by asking targeted questions, whether family members have a clear understanding of the patient's current health condition.	91.9	34	0.84
Healthcare professionals assess the needs of family members and evaluate potential risks that may affect their role in the patient's care.	75.7	28	0.51
Conditions				Conditions
The responsibilities for collecting, recording and managing family data are clearly defined and actively adhered to.	62.2	23	0.24	The responsibilities and division of tasks for collecting, recording and managing family data are clearly defined and actively adhered to.	52.9	18	0.06
The family assessment is documented in a fixed and easily identifiable location within the patient record.	81.1	30	0.62	Healthcare professionals conducting a family assessment possess the necessary competencies or are given the opportunity to further develop them.	67.6	23	0.35
All relevant healthcare professionals have access to the recorded family data.	64.9	24	0.30	Sufficient time and (physical) space are available to conduct the family assessment thoroughly and completely.	70.6	24	0.41
Healthcare professionals are trained in conducting a family assessment.	40.5	15	−0.19	There is agreement with the patient and family members on which information is recorded in the file.	52.9	18	0.06
Sufficient time is allocated within the care process to perform the family assessment thoroughly and accurately.	75.7	28	0.51	In cases of incapacity or minority, the relevant legal frameworks are followed, both in involving family members and in recording family‐related information.	94.1	32	0.88
The following aspects should be included in a family assessment: Family structure				The following aspects should be included in a family assessment: Family structure
The composition of the family.	59.5	22	0.19	The family composition, including the (partner) relationship, (cohabiting) children and pets.	70.6	24	0.41
Caregiving relationships within the family (who cares for whom?).	86.5	32	0.73	Important individuals outside the family (social network) who may play a role in the care or well‐being of the patient.	55.9	19	0.12
Significant individuals outside the family who may play a role in the care or well‐being of the patient.	62.2	23	0.24
Cultural, religious, or spiritual beliefs within the family that may influence the approach to illness, treatment, or patient care.	78.4	29	0.57
Family functioning				Family functioning
The primary point of contact within the family/network for care‐related matters concerning the patient.	94.6	35	0.89	How other family members of the patient are involved and informed, and how they maintain contact with each other and make joint care arrangements.	35.3	12	−0.29
How other family members of the patient are involved and informed.	32.4	12	−0.35
Whether there are topics within the family that are difficult to discuss or are intentionally avoided.	37.8	14	−0.24
Whether there are barriers, such as language or cultural differences, that affect communication.	94.6	35	0.89
The roles different family members play in supporting the patient.	62.2	23	0.24
3. Family needs and willingness a. To support the patient				Family needs and willingness
Which role(s) family members wish to fulfil/continue during the hospital stay (e.g., providing information or support, participating in decision‐making, caregiving tasks).	86.5	32	0.73	The (im‐)possibilities for the family to fulfil this role, considering factors such as work, other responsibilities, travel distance and finances.	52.9	18	0.06
What the wishes and expectations of family members are to fulfil these roles.	70.3	26	0.41	Assessing the (risk of) burden on family members (capacity vs. load).	67.6	23	0.35
b. To support the family
How family members cope with the patient's current situation.	59.5	22	0.19
What forms of support family members have (e.g., social network, religious/spiritual resources, professional help).	40.5	15	−0.19
Whether certain family members require additional support to cope with the patient's current situation.	59.5	22	0.19

Note: Bold CVR values indicate items falling below the critical Content Validity Ratio threshold.

^a n = 37, CVR threshold = 0.29.

^b n = 34, CVR threshold = 0.35.

All seven items under the concept Attitudes and Skills of Professionals met the critical CVR threshold and were therefore retained. Feedback on the item ‘Healthcare professionals assess the needs of family members and evaluate potential risks that may affect their role in the patient's care’ led to splitting it into two items: one addressing the assessment of needs and one addressing the evaluation of risks. Both were reassessed in Round 2 and confirmed as essential.

For the Conditions concept, two items were revised and reassessed based on expert input. The importance of professional competencies was confirmed, whereas defining responsibilities for family data management was not. Experts emphasized the need for sufficient time as well as adequate physical space; the latter was expanded, reassessed in Round 2 and deemed essential. In addition, experts highlighted the importance of obtaining consent for documenting family information. Two new items were therefore formulated, of which one was considered essential in Round 2.

Within Family Structure, items concerning care relationships within the family and cultural, religious, and spiritual considerations were immediately considered essential. Items on family composition and significant individuals outside the family were initially not supported. After clarification, family composition was reassessed in Round 2 and deemed essential.

For Family Functioning, Round 1 identified a family contact person and potential communication barriers as essential. The item concerning how other family members were informed was revised for Round 2 but was again deemed non‐essential. Items on difficult family communication and family role dynamics also failed to meet the threshold and were excluded.

Regarding Family Needs and Willingness, defining family roles and aligning expectations were confirmed as essential in Round 1. Items related to family support were not considered essential. Based on expert feedback, new items were introduced in Round 2, addressing (im‐)possibilities of role fulfilment and the risk of caregiver burden. Assessing caregiver burden was considered essential.

During the second round of the Delphi study, items that were revised or newly introduced based on expert recommendations were resubmitted for evaluation. Items that had already reached the consensus threshold in the first Delphi round were retained and are therefore not presented again in Table 2 for round 2.

After two Delphi rounds, a validated family assessment framework has been developed that can be used by healthcare professionals in the hospital (Table 3).

TABLE 3.

Validated family assessment framework for the hospital setting.

Family assessment framework
Attitudes/skills of healthcare professionals Consider the patient's preferences, wishes and values when involving family members. Encourage patients to bring family members to the hospital so that family can be involved in care and decision‐making process. Ask questions to gain insight into the perspectives of family members on the patient's care and situation. Listen attentively to what family members say and respond to their concerns, questions and suggestions. Use language and explanations that align with the language proficiency and experiences of family members. Verify, by asking targeted questions, whether family members have a clear understanding of the patient's current health condition. Assess the needs and expectations of family members. Evaluate potential risks, such as overload, that may affect a family member's role in care.
Conditions The family assessment is documented in a fixed and easily identifiable location within the patient record. All relevant healthcare professionals have access to the recorded family data. Healthcare professionals conducting a family assessment possess the necessary competencies or are given the opportunity to further develop them. Sufficient time and (physical) space are available to conduct the family assessment thoroughly and completely. In cases of incapacity or minority, the relevant legal frameworks are followed, both in involving family members and in recording family‐related information.
Content family assessment framework Family structure What is the family composition, including the (partner) relationship, (cohabiting) children and pets? Who cares for whom within the family? Are there cultural, religious, or spiritual beliefs within the family that may influence the approach to illness, treatment or patient care? Family functioning Who is the primary point of contact within the family for care‐related matters concerning the patient? Are there barriers, such as language or cultural differences, that affect communication? Family needs and willingness Which role(s) family members wish to fulfil during the hospital stay? (e.g., providing information or support, participating in decision‐making, caregiving tasks). What are the wishes and expectations of family members to fulfil these roles? Is there a (risk of) caregiver burden among family members?

3.3. Results Phase 3: Reflection on the Family Assessment Framework

In two focus group sessions, each consisting of five participants, reflections were conducted on the validate family assessment framework of phase 2. The 10 participants (six women and four men) were all family members (partners, parents, children or siblings) of patients who had been hospitalized in various departments of a hospital in the Netherlands (see Table 4).

TABLE 4.

Characteristics of the focus group respondents.

Respondent	Age (years)	Sex	Relation patient
1	49	Female	Daughter
2	81	Male	Spouse
3	65	Female	Sister
4	55	Female	Daughter
5	65	Male	Spouse
6	33	Female	Mother
7	77	Male	Spouse
8	50	Female	Spouse
9	37	Female	Daughter
10	42	Male	Son‐in‐law

All participating family members confirmed that the family assessment framework included concepts and items essential for acknowledging and supporting families during hospitalization. While they were given the opportunity to suggest additional items, no new items were proposed. Instead, their reflections served to further support and elaborate on the existing items. In structured group discussions, participants consistently found the content relevant, clear and reflective of their experiences. They also highlighted key attitudes, skills and contextual conditions that healthcare professionals require to effectively conduct a family assessment in the hospital setting. Table 5 is presenting the family assessment framework with family members' reflections. An overview of the reflection process, including codes and thematic refinements, is provided in File S6.

TABLE 5.

family assessment framework with family members' reflections.

Concepts with items	Family members' reflections
Attitudes and skills of healthcare professionals Consider the patient's preferences, wishes and values when involving family members. Encourage patients to bring family members to the hospital so that family can be involved in care and decision‐making process. Ask questions to gain insight into the perspectives of family members on the patient's care and situation. Listen attentively to what family members say and respond to their concerns, questions and suggestions. Use language and explanations that align with the language proficiency and experiences of family members. Verify, by asking targeted questions, whether family members have a clear understanding of the patient's current health condition. Assess the needs and expectations of family members. Evaluate potential risks, such as overload, that may affect a family member's role in care.	Attitudes and skills of healthcare professionals Empathic, open communication. Active listening and recognition family expertise. Visible follow‐up on family input.
Conditions The family assessment is documented in a fixed and easily identifiable location within the patient record. All relevant healthcare professionals have access to the recorded family data Healthcare professionals conducting a family assessment possess the necessary competencies or are given the opportunity to further develop them. Sufficient time and (physical) space are available to conduct the family assessment thoroughly and completely. In cases of incapacity or minority, the relevant legal frameworks are followed, both in involving family members and in recording family‐related information.	Conditions Allocate time for professional assessment and family reflection. Ensure a private, calm setting for open dialogue. Clearly document family information and ensure accessibility for involved healthcare professionals.
Content family assessment framework Family structure What is the family composition, including the (partner) relationship, (cohabiting) children and pets? Who cares for whom within the family? Are there cultural, religious, or spiritual beliefs within the family that may influence the approach to illness, treatment, or patient care?	Content family assessment framework Family structure Understand family composition and caregiving roles. Acknowledge cultural, religious and spiritual influences on treatment and end‐of‐life decisions. Identify key caregivers who hold essential knowledge about the patient.
Family functioning Who is the primary point of contact within the family for care‐related matters concerning the patient? Are there barriers, such as language or cultural differences, that affect communication?	Family functioning Identify a point of contact to support communication and coordination. Acknowledge the shared responsibility among family members in fulfilling the role of point of contact.
Family needs and willingness Which role(s) family members wish to fulfil during the hospital stay? What are the wishes and expectations of family members to fulfil these roles? Is there a (risk of) caregiver burden among family members?	Family needs and willingness Ask about family members willingness to provide care. Discuss what is feasible during hospitalization to align expectations and clarify roles. Consider caregiving capacity and well‐being to prevent overload.

3.3.1. Attitude and Skills of Healthcare Professionals

Family members reflected on the importance of empathic communication, highlighting the need for genuine contact, expressed interest and clear information. They prioritized professional attitudes and skills such as active listening, which enabled acknowledgement of their experiential knowledge and responsiveness to their input, favouring open dialogue over a rigid question‐answer format.

3.3.2. Conditions

Family members emphasized the need for adequate time and physical space to support meaningful assessments. This includes time for professionals to review information and for families to consider their role in care. They stressed that all relevant healthcare professionals should have access to the documented family data.

3.3.3. Family Structure

According to family members, understanding family composition and caregiving roles is essential, as cultural, religious and spiritual factors influence treatment decisions, particularly at the end of life. Identifying key caregivers helps clarify who holds crucial knowledge about the patient.

It is truly interconnected; I am convinced of that. How someone is at home, or the various issues that occur there—such as conflicts between children—inevitably influence what happens in the hospital. Respondent 8

3.3.4. Family Functioning

Family members saw identifying a point of contact as key to initiating communication and care coordination with healthcare professionals but noted that this role cannot always be fulfilled by one person alone.

As a contact person, you cannot do everything. It is nice if you can indicate that someone else can also receive the information. This way, a family member can also share the care. Respondent 5

3.3.5. Family's Willingness and Readiness to Support the Patient

Family members valued being asked about their willingness to contribute to care but stressed the need to discuss what is feasible from a family as well as a hospital perspective during hospitalization. Such dialogue helps align expectations, clarify roles and prevent overload by considering caregiving capacity and well‐being.

On some wards, they would ask me how I was doing and if I could still manage. Those were such important moments in my life and my experience. But then you go to another ward, and no one asks you anything. You might think, Can't you see that I'm not doing well? Respondent 5

3.4. Results Phase 4: Feasibility Testing of the Family Assessment Framework

A total of 10 nurses from four hospitals in the Netherlands tested the family assessment framework for its feasibility in clinical practice. The participants varied in age and professional experience and worked on both medical and surgical wards (see Table 6).

TABLE 6.

Characteristics of test panel (n = 10).

	N
Sex
Male	1
Female	9
Age range (years)
21–30	4
31–40	2
41–50	1
51–60	3
Work experience range (years)
0–10	5
11–20	2
21–30	2
31–40	1
Hospital department
Surgical	8
Medical	2

3.4.1. Clarity and Ease of Use of the Family Assessment Framework

Nurses generally perceived the family assessment framework as clear, concise and flexible. The keyword‐based prompts were valued as conversation starters rather than a rigid checklist, allowing adaptation to the patient's situation. As one nurse noted, ‘Format is certainly clear, nice short questions, keywords that help you think about what to ask and what to consider’. Although its practical value was emphasized, some questioned its use during very short hospital stays. As one nurse explained, ‘Sometimes you know an admission will last one or two weeks, then you have to approach it more consciously and document everything properly. But with shorter admissions, the question is whether you need to explore everything’. Other nurses described it more as ‘conversation tips’ than a structured tool. Suggestions included clarifying role descriptions to support consistent use.

3.4.2. Fit Within the Existing Work Process

The framework was seen as compatible with existing nursing workflows, particularly during nursing history taking in outpatient clinics or at admission. Several nurses indicated that the admission conversation provides a natural moment to address these family‐related topics and questions, allowing relevant information to be available from the start of the hospitalization. As one nurse explained: ‘I noticed it really fits within the admission conversation. Right from the beginning, during the history taking, you already obtain this information, which is the most practical’. Outpatient settings were considered more conducive due to greater time flexibility, but ward‐based conversations were valued for building trust. At the same time, respondents noted overlap with information collected by physicians, underscoring the importance of role clarity and information sharing between professionals. As one nurse stated: ‘It also needs to be clear who collects what information, so that we can make use of each other's information’.

3.4.3. Preconditions for Implementation

Successful implementation requires professionals to demonstrate the value of family involvement and clear agreements on responsibilities for conducting and documenting assessments. Respondents emphasized the importance of having a dedicated section in the electronic patient record, ensuring continuity and preventing repeated questioning by different professionals: ‘A fixed place in the EPR so that the colleague after you does not ask the same questions again’. Comprehensive training in communication and assessment skills, as well as protected time to ‘sit down with intention’, were emphasized as prerequisites. To sustain engagement, respondents suggested establishing a family care workgroup or implementation team to promote the use of the framework. Such a group could provide clinical teaching, guide colleagues in practice, and explain the importance of family involvement: ‘A workgroup that provides clinical lessons, keeps everyone on track a bit, and explains why involving family is so important’. The workgroup could also monitor outcomes and adapt the framework to fit clinical practice.

4. Discussion

This study developed and evaluated a practical family assessment framework with relevance for hospital settings. It outlines the essential aspects to discuss with family members at the start of admission, the required attitudes and skills of healthcare professionals, and the contextual conditions for implementation. Based on literature, validation by experts and reflection by family members, the resulting framework was assessed as relevant and complete. Feasibility testing indicated that while the framework is applicable in practice, successful integration requires adjustments to existing workflows, role clarifications and attention to professionals' attitudes and communication skills. This framework was developed for use in general hospital settings, where complex care trajectories and relatively short admissions require early alignment with family members.

The developed framework provides a structured approach for gathering essential information about the family of a patient at the start of a hospital admission. This foundational information is crucial to ensure that families are acknowledged from the outset and meaningfully involved throughout the care process [8]. Rather than serving as a simple checklist, the framework lays the groundwork for inclusive and collaborative care relationships [31], guiding healthcare professionals in involving families effectively from the first point of contact. A key distinguishing feature is its explicitly conversational nature, enabling a short, focused dialogue that fosters immediate relational connection, shared understanding and alignment of roles.

While existing models such as the Calgary Family Assessment Model (CFAM) provide comprehensive guidance for family assessment, they are not specifically tailored to the acute hospital context or to initiating brief, relationally oriented conversations at admission [1]. Similarly, structured assessment tools such as CHAT and D‐CHAT are questionnaire‐based instruments designed to systematically document care partners' contexts, preferences and needs in order to guide education, training and referral processes [17, 18].

By contrast, the present framework was developed to support a different but complementary purpose. Informed by FSN principles and previous research on family and healthcare professional perspectives, it focuses on facilitating early dialogical engagement with families, emphasizing acknowledgement of the family system, clarification of roles and alignment of expectations through concise conversations at the start of hospitalization. This focus on relational positioning ensures both theoretical grounding and practical relevance for hospital care.

The needs and concerns of family members can differ substantially, depending on the patient's medical condition, the caregiver's level of experience, and the emotional and social context in which caregiving occurs [32]. Furthermore, the extent to which families are able to be involved may be constrained by practical limitations such as employment obligations, caregiving responsibilities for others, legal or financial difficulties and health or transportation barriers [33, 34]. As such, the framework provides the necessary flexibility to accommodate a wide range of individual circumstances and care trajectories, supporting tailored approaches to family involvement in clinical practice.

Caregiving is a dynamic process, and an assessment at one point in time may not reflect the family's evolving circumstances. Therefore, the list should be viewed not as a one‐time assessment, but as the starting point of an ongoing dialogue. Periodic reassessment of family alignment, communication and support is necessary to respond to changes in the patient's condition or the caregiver's capacity [8, 35, 36]. The framework also emphasizes the importance of professionals' attitudes and skills. While the framework can guide the conversation, its value lies in how it is used—in how care professionals listen, involve families and translate the information into action considering the availability of time and resources [2, 37].

Moreover, the framework facilitates clarification of roles and expectations between professionals and family members. By explicitly discussing what family members can and are willing to do, as well as any limitations they face, care teams can more effectively coordinate care responsibilities. This supports not only immediate collaboration during hospitalization but also lays the groundwork for appropriate shared decision making and discharge planning [31].

4.1. Strength and Limitations

A key strength of this study is the systematic and iterative development of the family assessment framework, integrating evidence from the literature, expert validation, family member feedback and feasibility testing in clinical practice. Each phase built on the previous one, ensuring methodological rigour, relevance and usability across development stages. The two‐round Delphi panel ensured stakeholder consensus, allowed stepwise refinement and enhanced item clarity, with low‐content validity items being excluded when redundant or overlapping.

The Delphi panel was limited to professionals and researchers to ensure methodological rigour, focus on clinical applicability and maintain feasibility within the structured two‐round process. Including only experts allowed for precise assessment of item clarity, relevance and redundancy based on professional knowledge and experience in family nursing, which is essential for developing a usable assessment framework for clinical practice. Family perspectives were subsequently incorporated through focus groups to validate the framework's relevance, clarity and comprehensiveness from the user perspective. Only two focus groups were conducted due to practical constraints and evidence of data saturation: no substantial content gaps or divergent views emerged between the two groups. If critical omissions had been identified, additional focus groups would have been convened. Nonetheless, the limited number of focus groups may have constrained the diversity of family experiences represented.

Other limitations include the predominance of Dutch participants in the expert panel, potentially limiting cultural generalizability beyond North European contexts. Feasibility testing involved a limited number of nurses, most of whom had received prior family care training, which may limit generalizability and could introduce selection bias. Moreover, as this feasibility phase primarily provided qualitative insights into the framework's acceptability and practical use, further testing using quantitative feasibility indicators (e.g., eligibility and recruitment rates, fidelity, adherence and time burden) is warranted to enhance methodological rigour and assess broader applicability.

Because the search strategy did not explicitly include caregiving‐ or hospital‐specific terminology, instruments developed primarily to assess caregiving tasks, caregiver burden or task‐specific involvement—particularly within inpatient or acute care contexts—may be underrepresented. This reflects a deliberate focus on identifying theoretically grounded family assessment frameworks that address family functioning, roles and relationships, rather than task‐oriented caregiving assessments. As a result, the proposed framework places greater emphasis on relational, communicative and role‐alignment aspects of family involvement than on hands‐on caregiving activities. The findings should therefore be interpreted as a conceptually informed framework with relevance for hospital care, rather than as an exhaustive inventory of hospital‐tested caregiving instruments.

4.2. Recommendations for Further Research

Future research should focus on the ongoing validation, feasibility and potential refinement of the framework. It is recommended that such research be conducted with a larger and more heterogeneous sample, including nurses both with and without formal training in family nursing. Furthermore, implementing the framework in clinical settings with greater diversity among healthcare professionals, patients and family members may offer more comprehensive insights into its usability and relevance across different care contexts. Future studies should explore the framework's feasibility and impact using complementary quantitative and mixed‐method approaches to further substantiate its applicability in practice.

Moreover, as this study was conducted within a North European context, cross‐cultural validation is essential for broader applicability. In different sociocultural or healthcare environments, additional or alternative domains may emerge as relevant and should be explored accordingly.

Specifically, research should investigate the framework's impact on patient outcomes, such as the degree to which care aligns with patients' and families' expectations and their experiences of involvement and support. Additionally, attention should be given to how the framework supports collaboration among different healthcare professionals in delivering care, particularly in facilitating shared decision‐making with patients and families across disciplines.

4.3. Implications for Policy and Practice

Although the developed framework provides valuable guidance, its effectiveness depends not solely on completing the list, but on the dialogue it initiates. The process should not be reduced to a checkbox exercise; rather, the framework must serve as a starting point for meaningful conversations that foster mutual understanding and alignment of expectations. To avoid superficial application, it is essential that follow‐up actions are embedded within the care process.

Successful implementation of the framework requires attention to professional competencies and organizational embedding. All healthcare professionals require skills in family‐oriented communication and relational practice. These competencies should be integrated into educational curricula and supported through targeted training and periodic reinforcement to sustain competency over time. Integrating the framework into onboarding programmes, team‐based reflection, or mentorship structures may support consistent application in daily practice. In addition, organizations should ensure that the framework is embedded within existing workflows and documentation systems, so that information obtained during family conversations can be shared across the multidisciplinary team and revisited throughout the hospitalization trajectory.

In addition, it is crucial to clearly define the roles of different healthcare professionals in relation to the family assessment [21]. While feasibility testing and reflection suggested that nurses often consider themselves primarily responsible for conducting the family assessment, it is essential that physicians and other relevant professionals are also aware of the collected information and actively integrate it into their work and documentation. Healthcare professionals must align and share insights with each other, and together with the patient and family, jointly develop a diagnostic and treatment plan. Only when this approach is systematically implemented, role clarity is established, and the method is supported by the organization and reflected in daily practice can it truly contribute to sustained and effective family involvement throughout hospitalization.

5. Conclusion

This study presents a validated and practically feasible framework for assessing family structure, function and needs at the start of hospital admission. The framework provides healthcare professionals with a structured yet flexible tool to initiate and shape early conversations with families, acknowledging the diversity of caregiving situations and supporting meaningful involvement in care. Rather than being an endpoint, the framework marks the beginning of an ongoing process of communication and collaboration throughout the hospital stay. Its successful implementation depends not only on the framework itself but also on healthcare professionals' communicative competence, supportive organizational structures and integration into care planning. By fostering alignment between families and professionals, the framework has the potential to improve the quality of family involvement in hospital care.

Author Contributions

Josien M. Woldring: conceptualization, formal analysis, investigation, resources, data curation, writing – original draft, supervision, project administration. Wolter Paans: conceptualization, formal analysis, writing – review and editing. Reinold O. B. Gans: conceptualization, writing – review and editing. Marie Louise Luttik: conceptualization, formal analysis, writing – review and editing.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

File S1: scs70250‐sup‐0001‐FileS1.docx.

File S2: scs70250‐sup‐0002‐FileS2.docx.

File S3: scs70250‐sup‐0003‐FileS3.docx.

File S4: scs70250‐sup‐0004‐FileS4.docx.

File S5: scs70250‐sup‐0005‐FileS5.docx.

File S6: scs70250‐sup‐0006‐FileS6.docx.

Data Availability Statement

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