Commentary on Shields L (2010) Models of care: questioning family-centred care. Journal of Clinical Nursing 19, 2629–2638
Garth E Kendall, Senior Lecturer, School of Nursing and Midwifery, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, WA 6845, Australia. Telephone: +61 8 9266 2191.
We were delighted to read the recent paper by Shields (Shields 2010) because it draws attention to the way family-centred care (FCC) is commonly practised and identifies the requirement for nurses to find an evidence-base for that practice. We disagree, however, that FCC is almost impossible to implement and that it is time to question its continuation as a model of care. We suggest that FCC has its intellectual roots in several theoretical domains in addition to attachment theory. We argue that there is a gap between a theory which seeks to influence nursing practice so as to facilitate better health and developmental outcomes for children and current clinical practice which is focused on organisational goals and the fiscal bottom line.
We would like to draw attention to the theoretical basis of FCC and the empirical work that provides evidence for the importance of caring for the child in the context of the family. Rather than heralding the demise of FCC, this understanding, which has its roots a wide range of disciplines including epidemiology, psychology, sociology, anthropology and neuroscience, has the potential to transform the practice of nursing and the delivery of healthcare in general.
The person in the context of the family
The evidence supports the view that individuals and families are inseparable (Bronfenbrenner & Morris 2006). For the majority of children, their general development as well as their health and well-being is determined by their genetic inheritance and the care giving activities of family members, most notably the primary caregiver – usually the child’s mother. When a child has an accident, illness or a disability, the family may, or may not, seek health care assistance depending on a host of psychological, social and cultural factors. The point is this: other than in exceptional circumstances it is the family not any one single healthcare professional or organisation that takes responsibility for the health and well-being of the family member.
Social gradients and biological embedding
The evidence also supports the view that family socio-economic factors and social class influence the health outcomes of family members (Commission on Social Determinants of Health 2008). Children from disadvantaged families are less likely to have optimal health and well-being. Furthermore, children from disadvantaged families are more likely to be hospitalised for a range of conditions. There are several reasons why a social gradient exists for many health outcomes (Kendall et al. 2009). Family resources such as education and income are critically important. With regard to health, level of education is a proxy measure for general knowledge and understanding and the ability to access services appropriately. A low income often means that families experience poverty, or poverty relative to others in the community. Poverty diminishes access to the material necessities of life, including healthcare. Both absolute and relative poverty cause a great deal of stress and are associated with further life stressors, such as marital disharmony and frequent residential moves (Kendall & Li 2005). The experience of stress within the family affects all family members, including children. In the short-term, excessive stress diminishes cognitive functioning and can lead to anxiety and depression. In the long-term, both adults and children who live in chronically stressful situations may be affected physiologically as well as psychologically. The mechanisms that manage stress within the body can be altered at a very early age through a process which has been called ‘biological embedding’ (Hertzman & Frank 2006). The experience of caring for a family member with an illness or disability is, in itself, a stressful event which adds to the total burden. Increasingly, because of the demands placed on families to compete in the modern economy, many middle class families experience significant life-stress (Dockery et al. 2009). These families often need physical and emotional support to help them care for their sick child appropriately.
The implementation of FCC
The first step in implementing FCC is an assessment of the family’s psychological and social circumstances. The assessment of psychosocial circumstances is considered mandatory in most community child health settings. It would be deemed unprofessional, for example, not to identify that a young child’s mother was experiencing postnatal depression or that the family had no access to transport because of poverty. Rather than one or two randomised controlled trials, the evidence for this practice comes from several population-based cohort and intervention studies conducted in the USA, UK, Australia, Canada and elsewhere (Brooks-Gunn 2003, Olds et al. 2007).
We would hope there is little need to provide evidence that the development of a supportive relationship between health professional and the client/family is associated with better health outcomes. The practice of ‘therapeutic communication’, first established in clinical psychology, is now an integral part of professional nursing care and is used by health professionals in most disciplines. The basic model comprises the following: engagement; creating a safe environment; development of trust; focusing on the person or group and their view of the world; active listening; being non-judgemental; and displaying empathy, insight, understanding and acceptance (Cornwell & Goodrich 2009).
The sharing of knowledge and understanding, and capacity building, are synonymous with the concept of empowerment. Empowerment is a central element of modern educational theory and also health promotion theory which has been endorsed over many years by the World Health Organisation. Because many families lack knowledge and understanding, they experience a lack of control and are not always able to care for ill and disabled family members in a manner that is likely to lead to the best possible health outcomes. As mentioned previously, learning is particularly difficult in times of stress. A supportive approach fosters learning which, in turn, facilitates capacity building (Davis et al. 2002). Again, this approach is considered standard practice in community settings and there is a great deal of evidence of its effectiveness in improving health and well-being.
Additional resources will be required to implement FCC properly in the hospital setting. Paediatric nurses must resist the pressure from administrators to cut costs by taking on greater workloads. Economist Jim Heckman has made a cogent argument for vastly increased funding to better support children’s health and development (Heckman 2006) whilst Jack Shonkoff who chairs the US National Scientific Council on the Developing Child has suggested that efforts to prevent many common diseases of adulthood should begin in early childhood because a scientific consensus is emerging that the origins of adult disease are often found among developmental and biological disruptions occurring during the early years of life (Shonkoff et al. 2009). There remains considerable work for nurses to do, to use this body of knowledge and conduct research to show more directly how FCC in the hospital setting contributes to children’s health and developmental outcomes but there is a tangible reward for those who have a passion for this endeavour.