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. 2022 Jan 26;31(23-24):3338–3349. doi: 10.1111/jocn.16226

Factors associated with nurses’ positive attitudes towards families’ involvement in nursing care: A scoping review

Mayckel da Silva Barreto 1, Veronica Francisqueti Marquete 1, Camila Wohlenberg Camparoto 1, Cristina García‐Vivar 2,3,✉, Maria do Céu Barbieri‐Figueiredo 4, Sonia Silva Marcon 1
PMCID: PMC9786255  PMID: 35083808

Abstract

Aim

To map the factors associated with nurses’ positive attitudes towards families’ involvement in nursing care and to identify any existing gaps in knowledge.

Background

Several tools have been proposed to assess the attitudes, beliefs and practices of nurses towards families in different care contexts. However, there is a knowledge gap on how the results of these tools can identify the factors that are associated with more positive attitudes of nurses.

Design

A scoping review based on the steps proposed by the Joanna Briggs Institute.

Methods

Three independent reviewers searched the databases: PUBMED/Medline; LILACS; Virtual Health Library; PsycInfo; Google Scholar; SCOPUS and CINAHL, from 2006 to August 2021, guided by the question: What are the factors associated with nurses’ positive attitudes towards families´ involvement in nursing care, in studies that used one or both of the following two scales ‘Families’ Importance in Nursing Care‐ Nurses’ Attitudes’ and ‘Family Nursing Practice Scale’? This review was conducted in accordance with PRISMA‐ScR.

Results

Twenty‐six primary studies were identified, in which 9,620 nurses participated. Positive attitudes were associated with three types of variables: (a) personal—longer working career (42.3%) and older age (26.9%); (b) educational—higher level of academic education (30.8%) and family nursing education (23.0%); and (c) workplace—working in primary health care and/or outpatient clinics (34.6%) or in a unit with philosophy/approach to families (23.0%).

Conclusions

Personal variables such as age and time of service are non‐modifiable aspects, but educational and workplace variables are subject to intervention to improve nurses’ attitudes towards families’ involvement in nursing care. Continuing development programmes about family care can constitute important strategies to improve positive attitudes of nurses towards families in practice.

Relevance to clinical practice

Recognising the characteristics associated with nurses´ positive attitudes towards families may enable the development of tailored interventions that promote family‐focused care.

Keywords: attitudes, family, family nursing, nurses, scoping review

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

  • This article shows that positive attitudes of nurses towards the importance of involving families in clinical practice were associated with personal, educational and workplace variables.

  • The findings of this scoping review show that there are specific factors related to positive nurses´ attitudes towards families in each of the three variables: (a) personal—longer working career and older age of nurses; (b) educational—higher level of academic education and family nursing education; and (c) workplace—working in primary health care and/or outpatient clinics or in a unit with philosophy/approach towards the importance of involving families.

  • Personal variables such as age and time spent working as a nurse are non‐modifiable factors, but educational and workplace variables are subject to intervention to improve nurses’ positive attitudes towards families’ involvement in clinical practice.

1. INTRODUCTION

Family systems are affected when their members experience acute or chronic health problems (Shajan & Snell, 2019), but, at the same time, are an important source of support for patients (Hagedoorn et al., 2017). Therefore, the health‐disease process is a family matter and involving them in decision‐making, planning and care are essential to improved quality of care (Shajan & Snell, 2019). However, family involvement in care is a complex, multidetermined and interactive process that permeates the invitation of their presence, the frank, accessible, enlightening and welcoming communication and the provision of care that also meets their needs; consequently, it is important to enable their participation to result in an effective contribution to patient care (Barreto et al., 2018).

Evidence indicates that nurses’ attitudes towards families condition the nursing care process (Nóbrega et al., 2020; Østergaard et al., 2020). It is understood that ‘attitude’ is a cognitive state tied to values, beliefs or feelings and that predisposes behaviours or actions (Altmann, 2008). Thus, the attitude is composed of ‘affective, cognitive and behavioural aspects’ and configures response to a stimulus (Angelo et al., 2014). The presence of the patient's family in the care scenario awakens the attitudes of nurses towards it and involves feelings and emotions (affective aspect), thoughts and beliefs (cognitive aspect) and modes of action (behavioural aspect) (Angelo et al., 2014).

Nurses’ positive attitudes towards family involvement have been described as nurses recognising the importance of the family and adopting a supportive attitude towards the family to practice family‐focused care (Benzein et al., 2008). It is known that nurses feel more willing to engage with families in paediatric care (Angelo et al., 2014; Pascual‐Fernández et al., 2016) and in home care with patients living with chronic conditions (Hagedoorn et al., 2017; Nóbrega, Fernandes, Angelo, et al., 2020). In contrast, nurses show greater resistance to involving family members in contexts in which care includes invasive procedures for patients, such as in critical and acute situations (Barreto et al., 2018).

To understand and improve the nurse–family relationship, several tools have been proposed and disseminated to assess the attitudes, beliefs and practices of nurses towards patients’ families in different places and contexts of care production. Alfaro‐Díaz et al. (2019) conducted a systematic review to measure properties of five tools assessing nurses’ attitudes towards the importance of involving families in their clinical practice and found that the scale ‘Families’ Importance in Nursing Care ‐ Nurses’ Attitudes’ (FINC‐NA) by Benzein et al. (2008) and the ‘Family Nursing Practice Scale’ (FNPS) by Simpson and Tarrant (2006) obtained better psychometric evaluations. Therefore, the authors concluded that these two scales constituted the most appropriate measures to assess nurses’ attitudes regarding the involvement of families in care. That is why only studies that used the FINC‐NA and/or FNPS scales were included in this scoping review.

The original FINC‐NA scale was developed in Sweden and consists of 26 items with a 4‐point Likert scale (1—strongly disagree, 2—disagree, 3—agree and 4—strongly agree) (Benzein et al., 2008). The scale is divided into four subscales: family as a resource in nursing care (Fam‐RNC) with 10 items (α = 0.80) to measure nurses´ attitudes towards family presence and their participation in patient care; family as a conversational partner (Fam‐CP) with 8 items (α = 0.78) to measure acknowledging the family and communication between families and nurses; family as a burden (Fam‐B) with 4 items (α = 0.69) expressing negative attitudes towards families; and family as its own resource (Fam‐OR) with 4 items (α = 0.70) that relate to the families’ own coping system and support from nurses. Total score for the instrument ranges from 26 to 104, with higher scores indicating more positive attitudes of nurses to engage with families in care and provide them supportive care.

The FNPS was developed in Canada and consists of a 10‐item questionnaire with a 5‐point Likert scale and a section with five open‐ended questions to assess nurses’ attitudes towards working with families. The quantitative portion of the instrument is divided into two subscales representing nurses’ critical appraisal of their own family nursing practice (Practice Appraisal subscale) and nurses’ assessment of the nursing family relationship within their own practice (Nursing Family Relationship subscale). The score ranges from 10 to 50, and the lower the score, the greater the nurse's positive attitude towards engaging with the family and supporting them in practice (Simpson & Tarrant, 2006).

Both scales have been used in various contexts, including primary health care (Silva et al., 2013) and hospital care (Fernandes et al., 2015; Imanipour & Kiwanuka, 2020), and addressing different nursing specialties such as paediatrics (Angelo et al., 2014), cardiology (Gusdal et al., 2017), geriatrics (Misto, 2018) and mental health (Nóbrega, Fernandes, Angelo, et al., 2020). However, there is a knowledge gap on how the results of these tools, if matched with personal, educational and workplace variables, can identify factors which are associated with successful engagement and collaboration with the family. The compilation of these results can be useful to demonstrate, in different contexts of clinical practice, the factors associated with attitudes of nurses towards families and, thus, can support the implementation of strategies that favour the development of more positive attitudes in practice. Taking into account that patient and family centred‐care model is recommended by international organisations because it promotes quality and safety in health care (Dhurjati et al., 2019; International Family Nursing Association, 2017), knowing the main factors associated with nurses´ attitudes towards the importance of involving families in care is of interest to the nurses themselves, nursing supervisors as well as to health managers.

An extensive search was performed but no bibliometric study was identified that mapped the publications about the factors associated with the positive attitudes of nurses in relation to the involvement of families in care, which justifies conducting this scoping review. Furthermore, by shedding light on this issue, it will be possible to identify gaps in the literature and to provide for a new systematic review to build an explanatory model that demonstrates the causes and effects of the different factors that influence nurses’ positive attitudes towards families.

2. AIM

This study aimed to map the factors associated with nurses’ positive attitudes towards families’ involvement in nursing care, and to identify any existing gaps in knowledge.

3. METHODS

3.1. Design

A scoping review was carried out following the nine steps of the Joanna Briggs Institute (JBI) framework for scoping reviews (Peters et al., 2020), since it expands the work of Arksey and O’Malley (2005) and Levac et al., (2010) on scoping reviews.

The research question guiding this study was as follows: what are the factors which are associated with nurses´ successful engagement and collaboration with families in practice, in studies that used FINC‐NA and/or FNPS scales? To elaborate the review question, the PCC (Population; Concept and Context) approach was used, as presented in Table 1.

TABLE 1.

Presentation of the PCC strategy applied in the scoping review, 2021

Question : what are the factors which are associated with nurses´ successful engagement and collaboration with families in practice, in studies that used FINC‐NA and/or FNP scales?
Population Considered studies conducted with registered nurses who work in clinical practice (including bedside nurses and nurse managers), regardless of the type of education (i.e., specialist, doctors and advanced nurse practitioners).
Concept Studies that explored factors associated with positive nurses’ attitudes towards the involvement of families in nursing care were considered, evaluated through the FINC‐NA and/or FNPS instruments;
Context Considered studies conducted in varied care configurations, including, but not limited to, hospitals, primary healthcare units, clinics, outpatient clinics and schools, in which nurses´ attitudes were assessed with FINC‐NA and/or FNPS.
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3.2. Protocol and registration

To ensure accuracy to this review, its protocol followed the principles contained in the Preferred Reporting Items for Systematic reviews and Meta‐Analyses extension for Scoping Reviews (PRISMA‐ScR) (Tricco et al., 2018) (Supplementary File S1). Furthermore, the protocol was reviewed by three external evaluators, specialists in literature review studies and/or in the FINC‐NA and/or FNPS instruments, to indicate possible methodological weaknesses prior to conducting searches and analyses, and then, the protocol was registered on the research repository Figshare Dataset (https://doi.org/10.6084/m9.figshare.14374502.v2) and published in a peer‐reviewed journal of nursing (Barreto et al. 2022).

3.3. Eligibility criteria

To determine the eligibility of primary studies, the following inclusion criteria were adopted: (a) quantitative or mixed‐method research, conducted with registered nurses (population) working in various fields, for example hospitals, basic health units, clinics, outpatient clinics and schools (context), who employed FINC‐NA and/or FNPS in their studies, plus sociodemographic and/or work and/or educational profile questionnaires, which contain statistical analysis to identify factors associated with the outcome (concept); (b) articles published from 2006 for those that used FNPS and from 2008 for FINC‐NA, until August 2021, in peer‐reviewed journals; and (c) publications, available electronically in full, in the languages: English, Portuguese or Spanish.

In turn, the exclusion criteria were (a) studies conducted with nurse educators or undergraduate nursing students who were not directly involved in nursing practice; (b) intervention studies that evaluated only the changes in nurses’ attitude towards families in the pre‐ and post‐test, as in these cases there was no analysis of positive attitudes with personal, educational and workplace characteristics; and (c) methodological studies on the presentation, refinement, translation, adaptation or validation of the instruments.

3.4. Search strategies

The search was conducted between July and August 2021. To identify potential studies, the search took place in three stages. First, the initial search was conducted limited to three online databases PUBMED/Medline, CINAHL and Scopus. This search was conducted with the following descriptors Medical Subject Headings (MeSH): “family nursing” OR “nursing” OR “family nurse practitioners” AND “attitude” AND “nursing care” OR “hospitals” OR “home care services” OR “ambulatory care”; followed by an analysis of the words set out in the title and summary of the articles identified and the terms used in the index. This search resulted in the return of several studies that had not used the tools under investigation and, therefore, did not fit the inclusion criteria. Thus, after discussion with a librarian, it was decided to use the titles and acronyms of the two instruments (FINC‐NA and FNPS). This is because, as the purpose of this review was to map the publications that used the two instruments, it was not appropriate to employ descriptors, keywords and very comprehensive indexes.

In the second stage, a search was performed in all databases: PUBMED/Medline; LILACS; Virtual Health Library (VHL); PsycInfo; Google Scholar; SCOPUS; and CINAHL, using the instrument title and its acronyms joined by Boolean ‘OR’. Search strategies performed in the selected databases are presented in Table 2.

TABLE 2.

Search strategies performed in the selected databases

Database Search strategy
Pubmed/Medline ((Families’ Importance in Nursing Care ‐ Nurses’ Attitudes[Title/Abstract]) OR (FINC‐NA[Title/Abstract]) OR (Family Nursing Practice Scale[Title/Abstract]) OR (FNPS[Title/Abstract]))
LILACS (Families’ Importance in Nursing Care ‐ Nurses’ Attitudes OR FINC‐NA) OR (Family Nursing Practice Scale OR FNPS)
Virtual Health Library (Families’ Importance in Nursing Care ‐ Nurses’ Attitudes OR FINC‐NA) OR (Family Nursing Practice Scale OR FNPS)
PsycInfo Any Field: “Families’ Importance in Nursing Care ‐ Nurses’ Attitudes” OR “FINC‐NA” OR “Family Nursing Practice Scale” OR “FNPS”
SCOPUS (TITLE‐ABS‐KEY (“Families’ Importance in Nursing Care ‐ Nurses’ Attitudes”) OR TITLE‐ABS‐KEY (“FINC‐NA”) OR TITLE‐ABS‐KEY (“Family Nursing Practice Scale”) OR TITLE‐ABS‐KEY (“FNPS”)
CINAHL (“Families’ Importance in Nursing Care ‐ Nurses’ Attitudes” OR “FINC‐NA”) OR (“Family Nursing Practice Scale OR “FNPS”)
Google Scholar “Families’ Importance in Nursing Care ‐ Nurses’ Attitudes” OR “FINC‐NA” OR “Family Nursing Practice Scale” OR “FNPS”
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In the third and final stage, the reference lists of the included articles were consulted to identify other potential and additional studies.

The searches and the selection of the articles were done independently by three members of the research team. Initially, the analysis was performed by title and abstract, and the researchers met to discuss the identified studies, applying the inclusion and exclusion criteria. Then, the full‐text analysis was performed, again independently by the three researchers, to determine studies for inclusion. Inconsistencies in the selection of studies were discussed with two senior researchers from the group, with a view to achieving consensus. At the end, the sample consisted of 26 primary studies (Figure 1).

FIGURE 1.

FIGURE 1

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PRISMA Flowchart. Identification, selection and inclusion of Scoping Review studies

3.5. Study selection and data extraction

After inclusion of the full‐text studies, three members of the research team independently read and conduct data extraction, through a tool elaborated by the authors, which was based on the aim of this review and the current literature on attitudes of nurses towards family's involvement. After the first two analyses, these researchers met to discuss the extraction tool, the quality of the review and possible divergences. Faced with inconsistencies in data extraction, senior investigators from the group were consulted for discussion and consensus.

The tool for extraction included the following variables: characterisation of the publication (year of publication, funding agency, journal and training of the authors); contextual characterisation (country of research development, nurses’ work context—primary health care, outpatient clinic; clinic; hospital environment; emergencies, among others—and area of specialty—mental health, paediatrics, oncology, maternal and child, among others); methodological characterisation (sample size aspects of sample representativeness and statistical tests applied); and characterisation of the outcome (main factors associated with the positive attitude of nurses towards the involvement of families, such as sex; marital status; courses on family nursing; time of experience; complementary academic training, among others).

3.6. Analysis, synthesis and presentation of data

After the extraction of information from the included studies, the data were analysed considering the research question. As the factors statistically associated with the outcome of interest were multiple, it was decided to group them into ‘personal’, ‘professional’ and ‘educational’ variables, considering whether the factors were related to personal life (i.e., age, sex and marital status); professional (i.e., being a supervisor and workplace); or educational (i.e., level of additional training and taking family nursing courses). The results were presented in narrative format, accompanied by resources for visual representation of the compiled data, through tables.

3.7. Ethical considerations

Since it was a secondary study that did not involve data collection with humans, it was not necessary to analyse the Ethics Committee, but procedures were considered to ensure the quality and accuracy of the review, namely the principles contained in PRISMA‐ScR (Tricco et al., 2018). Additionally, recommendations of the PAGER framework for improving the quality of reporting of scoping reviews were considered (Bradbury‐Jones et al., 2021).

4. RESULTS

4.1. Geographical location of the studies

Twenty‐six studies were included in this review, of which 9,620 nurses participated. Studies were conducted in Portugal (23.1%), Brazil (15.4%) and northern Europe—Sweden (19.2%), Iceland (11.5%) and Denmark (7.7%).

4.2. Characteristics of included studies

Of the included studies, 19.2% focused on the area of mental health and 11.5% on pediatrics. Most of the data collection (76.9%) was carried out with nurses working in the hospital environment. The most used instrument was FINC‐NA, alone (84.6%) or in association with FNPS (3.8%). The majority of the studies (61.5%) reported not having received any funding for the development of the research. Some studies (38.5%) did not make clear the process of translation and/or validation of the scales (6 studies) or performed only one semantic equivalence process (4 studies) and another 34.6% did not clarify whether Cronbach's alpha was evaluated (Table 3).

TABLE 3.

Distribution of studies included in the scoping review according to characterisation variables

Authors Year Country Specialty Context Instrument Participants Funding Validation and adaptation Cronbach's Alpha
Benzein et al. 2008 Sweden Does not specify Hospital; PHC; and others FINC‐NA 634 Yes Original Yes
Sveinbjarnardottir et al. 2011 Iceland Mental health Hospital FINC‐NA 81 Yes Yes No
Silva et al. 2013 Portugal Does not specify PHC FINC‐NA 871 No Yes No
Angelo et al. 2014 Brazil Paediatrics Hospital FINC‐NA 50 No Semantic equivalence No
Blöndal et al. 2014 Iceland Surgical nursing Hospital FINC‐NA 211 No Yes Yes
Linnarsson et al. 2015 Sweden Emergency care Hospital FINC‐NA 457 Yes Original Yes
Moreira & Almeida 2015 Portugal Does not specify PHC FINC‐NA 871 No Yes No
Fernandes et al. 2015 Portugal Does not specify Hospital FINC‐NA 160 No Yes Yes
Pascual‐Fernández et al. 2016 Spain Paediatrics Hospital FINC‐NA 186 No Yes Yes
Luttik et al. 2016 Belgium, Norway, Sweden and Denmark Cardiology Hospital and others FINC‐NA 425 No Original and only translated into Dutch and French No
Gusdal et al. 2017 Sweden Cardiology Hospital and PHC FINC‐NA 303 No Original Yes
Fernandes et al. 2018 Portugal Mental health PHC FINC‐NA 328 No Yes Yes
Hoplock et al. 2019 Canada Does not specify Hospital and home FINC‐NA 139 Yes Does not clarify Yes
Østergaard et al. 2020 Denmark Does not specify Hospital, PHC, psychiatry FINC‐NA 1720 No Does not clarify Yes
Nóbrega, Fernandes, Zerbetto, et al. 2020 Brazil Mental health PHC FINC‐NA 257 No Semantic equivalence Yes
Hagedoorn et al. 2020 Netherlands Does not specify Hospital and home FINC‐NA 426 No Yes No
Nóbrega, Fernandes, Angelo, et al. 2020 Brazil and Portugal Mental health PHC FINC‐NA 500 No

Yes

Semantic equivalence (Brazil)

 Yes
Imanipour and Kiwanuka a 2020 Uganda Intensive Care Hospital FINC‐NA 116 No Does not clarify Yes
Hori et al. 2020 Japan Medical‐surgical Hospital FINC‐NA 416 Yes Yes No
Boyamian et al. 2021 Brazil Neonatology Hospital FINC‐NA 145 Yes Semantic equivalence No
Cranley et al. 2021 Sweden, Canada and China Does not specify Hospital; PHC; and others FINC‐NA 740 No Original Yes
Fernandes et al 2021 Portugal Does not specify Hospital; PHC; and others FINC‐NA 192 No Yes Yes
Hsiao and Tsai 2015 Taiwan Mental health Emergency and psychiatric rehabilitation unit FINC‐NA and FNPS 175 Yes

FINC‐NA ‐ Does not clarity

FNPS ‐ Original

 Yes
Brown et al. 2017 USA School health School FNPS 97 Yes Original Yes
Svavarsdottir et al. 2018 Iceland Does not specify Hospital FNPS 60 Yes Does not clarify Yes
Misto 2018 USA Geriatrics Hospital FNPS 60 Yes Original No
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Abbreviations: PHC, primary health care; USA, United States of America.

a

In this study, the authors used a scale entitled FNPS, but different from the scale being analysed in this scoping review, so the data referring to it were not considered.

4.3. Factors associated with nurses’ positive attitudes

Regarding the factors associated with the positive attitudes of nurses towards families, the predominance of those with greater professional experience (42.3%) was found in the personal variables, followed by older age (26.9%). In the educational variables, we highlighted the nurses who had higher academic education, such as post‐graduation, masters and doctorate (30.7%), followed by those who had a degree in family nursing (19.2%), and in the work variables, there was a predominance of those who worked in PHC/outpatient clinics (34.6%) and those working in units where there was philosophy/approach to families (23.0%) (Table 4).

TABLE 4.

Characteristics of nurses associated with a more positive attitude towards the families’ involvement in nursing care (n = 26)

Characteristics
Personal variables N %
Longer professional career 11 42.3
Older age 07 26.9
Having experience of family illness 04 15.4
Female 04 15.4
Greater empathy 02 7.7
Stable relationship 01 3.8
Educational variables
Higher level of academic training 08 30.7
Nursing education of families 05 19.2
Take a short course 01 3.8
Workplace variables
Working in PHC/outpatient clinics 09 34.6
Working in unity with philosophy/approach of families 06 23.0
Being a supervisor 04 15.4
Working specifically with families 03 11.5
Working in paediatrics 03 11.5
Working in geriatrics 01 3.8
Working in maternity 01 3.8
Lower weekly workload 01 3.8
Increased job satisfaction 01 3.8
Carry out family‐oriented interventions 01 3.8
Routinely include family members in care 01 3.8
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Abbreviations: PHC, primary health care.

4.4. Factors associated with positive attitudes in the FINC‐NA subscales

When analysing the subscales of the FINC‐NA instrument, it was possible to identify that in the subscale ‘family as a resource in care’ the positive attitude of nurses was more frequently associated with older age (33.3%); higher level of academic education (40.0%); and work in PHC/outpatient clinics (40.0%).

Regarding the subscale ‘family as a conversational partner’, there was an association with longer working time and older age (33.3% each); higher level of academic training and having training in family nursing (26.6% each); and have an approach to families at work (40.0%). On the contrary, in the subscale ‘family as a burden’ (inverted score) was associated with the longest time of professional performance (46.6%); higher level of academic education (33.3%); and work in PHC/outpatient clinics (26.6%).

Finally, in the subscale ‘family as own resource’ was more often associated with longer professional career and older age (33.3% each); higher level of academic education (20.0%); and work in PHC/outpatient clinic and have an approach to families in the workplace (26.6% each) (Table 5).

TABLE 5.

Distribution of variables associated with a more positive attitude towards families, according to subscales of the FINC‐NA instrument (n = 15 a )

Subscales of FINC‐NA Fam‐RNC Fam‐CP Fam‐B Fam‐OR
Personal variables N % N % N % N %
Longer professional career 04 26.6 05 33.3 07 46.6 05 33.3
Older age 05 33.3 05 33.3 04 26.6 05 33.3
Female 04 26.6 03 20.0 01 6.66 02 13.3
Having experience of family illness 01 6.66 03 20.0 02 13.3 02 13.3
Educational variables
Higher level of academic training 06 40.0 04 26.6 05 33.3 03 20.0
Nursing education of families 04 26.6 04 26.6 02 13.3 ‐‐ ‐‐
Take a short course ‐‐ ‐‐ 01 6.66 ‐‐ ‐‐ ‐‐ ‐‐
Workplace variables
Working in PHC/outpatient clinic 06 40.0 05 33.3 04 26.6 04 26.6
Having a family approach at work 04 26.6 06 40.0 03 20.0 04 26.6
Working in paediatrics 02 13.3 03 20.0 01 6.66 02 13.3
Being a supervisor 02 13.3 03 20.0 02 13.3 02 13.3
Working specifically with families 01 6.66 02 13.3 01 6.66 01 6.66
Working in geriatrics 01 6.66 01 6.66 ‐‐ ‐‐ ‐‐ ‐‐
Working in maternity 01 6.66 01 6.66 ‐‐ ‐‐ 01 6.66
Working in mental health ‐‐ ‐‐ 01 6.66 ‐‐ ‐‐
Carry out interventions for the family 01 6.66 01 6.66 01 6.66 ‐‐ ‐‐
Include family members in care 01 6.66 01 6.66 01 6.66 ‐‐ ‐‐
Lower weekly workload ‐‐ ‐‐ ‐‐ ‐‐ 01 6.66 ‐‐ ‐‐
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Abbreviation: Fam‐B, family as a burden; Fam‐CP, family as a conversational partner; Fam‐OR, family as own resource; Fam‐RNC, family as a resource in nursing care.

a

Of the total number of studies that applied FINC‐NA, 15 present subscale analyses.

5. DISCUSSION

5.1. Studies limited to geographic areas and healthcare contexts

In this scoping review, it was found that most studies were conducted in Portugal, Brazil and Scandinavian countries. FINC‐NA (used in 88.4% of the studies included in this review) was translated into Portuguese and validated for the context of Portugal in 2011 (Oliveira et al., 2011) and underwent a process of semantic equivalence in Brazil (Angelo et al., 2014), which justifies the fact that most of the studies under analysis originate from these two countries. In turn, the Scandinavian countries stood out because the instrument was originally developed by Swedish nurses (Benzein et al., 2008). However, professional family nursing organisations have sought to disseminate the use of these tools, allowing them to be validated and applied in different contexts and scenarios.

It is known that the families of patients are present in the most varied contexts of care, from PHC and home to critical and emergency care. However, although nurses’ attitudes are more favourable to families in home care environments and primary healthcare units (Hagedoorn et al., 2017; Silva et al., 2013) and the need for family support is very well established in the contexts of chronicity and end‐of‐life care (García‐Vivar et al., 2019), this review shows that most studies were developed in the hospital context. This situation may be related to the fact that the hospital environment is responsible for absorbing a high percentage of the nursing workforce. In this review, one study from the United States presenting nurses´ attitudes towards families in the context of school health was found (Brown et al., 2017). It should be noted that in regions such as Australia, Canada, Europe or United States, the role of nurses in schools is common (Morse et al., 2020), but in Latin America, for example, this practice is still incipient (Ceballo‐Mella et al., 2020). Considering the importance of the school nurse's role in providing support to young people and their families, future studies need to address nurses´ attitudes towards families´ involvement in the school environment.

Besides, it seems important to highlight that in some studies it was not possible to clarify how the process of adaptation and/or cross‐cultural validation was for the context/country where data collection was carried out. Besides, some studies reported only having performed a process of semantic equivalence between, for example the Portuguese of Portugal and Brazil, which can affect the quality of the results obtained, since the translation process, per se, does not guarantee the maintenance of the accuracy of the instrument. In addition, almost one third of the studies did not refer evaluation of Cronbach's Alpha, which may call into check the reliability of the internal consistency of the scale for the population surveyed. This is because the items of an instrument, in addition to being linguistically translated, must be adapted to preserve the validity of their content culturally, so that when applied in different populations it is possible to estimate the reliability of the application and compare the findings (Beaton et al., 2000). Thus, it is suggested that family nursing researchers look at the description of methodological aspects in their research reports, so to allow readers to identify the requirements of quality and accuracy in an easy way.

5.2. Professional experience and older age as contributing factors to positive attitudes

This scoping review showed that greater professional experience, followed by older age, are factors associated with nurses’ positive attitudes towards family involvement. It is noteworthy that there may be an overlap between these variables, because nurses with longer professional working time, in general, are those with older age. The recurrent association between working time/age with positive attitude can be explained by the low level of confidence that early‐career nurses generally present to work with families. In addition, in novice nurses the use of technical skills predominates, so the focus is often on physical care, patient safety and relationship with the team (Gusdal et al., 2017).

Therefore, it seems important to train early‐career nurses in family assessment, communication with families and family intervention. Simulation‐based training can be used to create structured activities that represent potential situations in practice with families (Van Gelderen et al., 2019). In addition, it is recommended to train nurses about the use of family scales as an easy tool to incorporate into clinical practice. Using family tools can help early‐career nurses feel more confident to interact with families and recognise them as facilitators and beneficial in the healthcare process (Hoplock et al., 2019). Furthermore, it may enable young nurses to become more critical, reflective and proactive in considering their beliefs and actions when caring for families (Hoplock et al., 2019).

5.3. Higher education level and family nursing courses as contributing factors to positive attitudes

The present review also found that a higher educational level, either in the curricula of graduate studies or specific courses on family nursing, was associated with positive attitude of nurses towards involving families in care. Other authors have also identified that knowledge about the benefits of the family presence in care was associated with advanced levels of study, that in turn provide more positive attitudes and behaviours of nurses towards family members (Angelo et al., 2014; Østergaard et al., 2020). Hence, it seems important to offer certified continuing professional education on family nursing throughout the nursing professional career, so nurses will continue to be competent in family care in the different healthcare contexts. Even more so when it has been shown that this type of training is cost‐effective and improves the satisfaction of nurses, patients and families (Hagedoorn et al., 2020). The participation in family clinical simulation scenarios is particularly recommended for early‐career nurses to enhance their skills for communication with families and attitudes to family care.

5.4. Healthy work environment as contributing factor to positive attitudes

Occupying the position of supervisor was found another factor associated with positive attitudes towards the involvement of families in care. This could be because being supervisor in most cases requires greater professional experience, a higher level of training (Miguélez‐Chamorro et al., 2019) and, consequently, greater critical knowledge about the importance of the family.

Contact, conviviality and the relationship established between nurses and families in the work environment are also important factors for the involvement of families in care. This is because, as evidenced in this review, nurses who worked in health units with a philosophy/approach to families and/or who work specifically with families or who included other family members in care and performed interventions for the whole family had more positive attitudes towards family involvement. Therefore, to increase a family‐focused approach in nursing practice, it is essential that healthcare organisations support through explicit institutional policies the importance of family involvement in care (Luttik et al., 2016).

In addition, it was identified that higher satisfaction and lower weekly workload were associated with more positive attitudes of nurses towards families. These variables may be related to greater satisfaction with the work activities performed. Moreover, a smaller weekly workload enables more responsible, personalised and comprehensive care to patients and their families (Silva et al., 2020). Therefore, managers should defend and support healthy work environments that integrate standards, such as appropriate staffing, adequate working hours, places to rest, and true collaboration to help produce effective and sustainable outcomes for patients, families and nurses (Dias et al., 2019). Furthermore, a family‐focused care environment is recommended due to the identified benefits for both nurses and patients/ families: it can improve the patient's and family's experience with care and their satisfaction with therapeutic decision‐making, increase professional satisfaction, and lead to more effective and quality care (Gusdal et al., 2017; Hagedoorn et al., 2017).

5.5. Strengths and limitations

The review process was conducted at a single time in a variety of databases, so it is recognised that searches may have been lost. However, the search included three languages to provide a broader and more international view of current research. The non‐inclusion of grey literature may also be a potential limitation, considering that some relevant research may be lost. However, to identify the best and accurate available evidence, it was decided to select only studies published in peer‐reviewed journals. A strength of this study was the searches and the process of selection of the articles that were done independently by three members of the research team.

6. CONCLUSIONS

This scoping review contributes to mapping the studies that applied the FINC‐NA and/or the FNPS as data collection instruments and is unique in the exploration of international research published in different languages and contexts of family nursing care. At the same time, this scoping review identified the characteristics associated with more positive attitudes of nurses regarding the involvement of families in nursing care, in different contexts and scenarios of care. In this regard, this review found that nurses´ positive attitudes towards families were more frequently associated with three types of variables: (a) personal—longer working time and older age; (b) educational—higher level of academic education and training in family nursing; and (c) work—work in primary care and/or outpatient clinics and work in a unit with philosophy/family approach.

It is noteworthy that personal variables such as age and time of nursing service are non‐modifiable aspects, but educational and work variables are subject to intervention. Thus, it is possible to improve the satisfaction of professionals with work; improve the training/preparation of nurses for family care; and stimulate the development of institutional policies that support the practice of nurses with families.

To respond to the gaps identified in this review, future research is required to assess the attitudes of nurses working in contexts that are still under‐explored, such as school, oncology, palliative care, chronic respiratory diseases, dementia and immigration/refuge. In addition, it is suggested that more studies apply the FNPS as an instrument to assess the attitudes of nurses in order to have more data on the application of this scale that has been under‐utilised in contrast with the FINC‐NA scale. Finally, it is suggested that family nursing researchers comply with aspects of methodological rigour for the application of constructed and validated instruments.

7. RELEVANCE TO CLINICAL PRACTICE

The findings of this review can help managers to make evidence‐based decisions that promote the factors that contribute to nurses´ successful engagement with families according to the demographic and educational characteristics of the nurses and the setting in which care is provided. Patient and family‐focused care is ongoing challenge in health care, so recognising the characteristics associated with nurses´ positive attitudes towards families may enable the development of tailored nursing interventions that meet specific needs of families. Additionally, certified continuing professional education on family nursing throughout the nursing professional career, and in particular for young nurses, must be a commitment of nursing leaders at the different levels of care (hospitals, primary and community care centres, nursing homes, etc.).

On the other side, the development of synergies between academic institutions and nurse practice managers is necessary to identify the needs and expectations about family care in clinical practice in order to prepare nursing students, future health professionals, for family‐focused care, especially in some areas where the family plays a key role in the recovery of patients, such as intensive care, paediatrics, oncology and home care.

Finally, future research is required to explore the views of nurses about the barriers and new proposals to involve in a systematic and protocolised way the needs of families of patients living with a complex chronic disease, such as cardiovascular disease, dementia, cancer or situations that involve a high level of dependency in patients and the need for long‐term care by family caregivers.

Acknowledgements

Open access funding provided by Universidad Pública de Navarra

CONFLICT OF INTEREST

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

AUTHOR CONTRIBUTION

Made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; Involved in drafting the manuscript or revising it critically for important intellectual content; Give final approval of the version to be published; Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: MSB, VFM, CWC, CGV, MCBF, SSM.

Supporting information

File S1

Click here for additional data file. (107.3KB, docx)

Barreto, M. S. , Marquete, V. F. , Camparoto, C. W. , García‐Vivar, C. , Barbieri‐Figueiredo, M. D. C. , & Marcon, S. S. (2022). Factors associated with nurses’ positive attitudes towards families’ involvement in nursing care: A scoping review. Journal of Clinical Nursing, 31, 3338–3349. 10.1111/jocn.16226

Funding information

The authors received no financial support for the research, authorship and/or publication of this article.

Contributor Information

Mayckel da Silva Barreto, @MayckelBarreto.

Cristina García‐Vivar, Email: cristina.garciavivar@unavarra.es, @cgarvivar.

Maria do Céu Barbieri‐Figueiredo, @CeuBarbieri.

DATA AVAILABILITY STATEMENT

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

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