Family Nursing Practice and Family Importance in Care in Intensive Care Units: Perspectives of Nurses working in Intensive Care Units

The analysis of family-focused nursing practice is fundamental for advancing family nursing in intensive care settings, yet this area remains less studied in sub-Saharan Africa. Nurses’ attitudes presuppose an assessment of what nurses are willing to do and objection of certain practices. The purpose of this study was to assess the correlation between family nursing practice and nurses’ attitudes towards family importance in care in adult intensive care units (ICU). A cross-sectional study was conducted among 116 nurses working in adult intensive care units using census sampling method. The instruments used for data collection included the Family Nursing Practice Scale (FNPS) and the Family Importance in Care-Nurses’ attitudes (FINC-NA). The mean score of FNPS was 38.7±12.7 whilst the mean score of FINC-NA was 90.6±14.7. The Pearson’s product-moment correlation revealed a positive relationship was revealed between FNPS and FINC-NA (r=0.6; p<0.01) The ndings identied that most ICU nurses had a positive attitude towards family importance in care though their family nursing practice was moderate. In attempt to reach desirable nursing practice, it is recommended to develop practical and educational strategies aimed at improving of family care. This is especially useful to families in sub Saharan countries were families play a vital role in caring for the patient during admission and after discharge.


Background
The need for intensive care services and survival from critical illnesses continue to increase (Maguire & Carson, 2013). This is due to advances in intensive care, expansion of capacity to cater for the ongoing novel coronavirus virus disease 2019 (COVID- 19) pandemic and the increasing older population. Consequently, as the number of patients requiring treatment in Intensive Care Units (ICU) increases, a proportional number of family members will experience the journey of admission of a family members in ICU (Hetland, Hickman, McAndrew, & Daly, 2017). Nurses will have more encounters with the patients' families. As such, it is imperative for nurses to recognize these trends and to support the families using various interventions. This calls for more demands on nurses to utilize family nursing practices in all care settings (Simpson & Tarrant, 2006).
Critical illnesses or injuries not only affect the patient. They also have substantial impact on the whole family, owing to the fact that the patient forms half of the patient while the other half is the patient's family unit (Bell, 2013). Occasionally, illness of one of the family members in uences the family's health, perceptions and behaviors in various ways (Minton,  Nurses and other ICU personnel should recognize the importance of ful lling family needs (Olding et al., 2016 Luttik (2017) argued that an effective encounter between nurses and family members is notably in uenced by attitude of nurses towards family importance in care. Additional research highlighting the link between FNP and FINC-NA needs to be nuanced. Therefore, this study aimed to assess the correlation between family nursing practice and nurses' attitude towards family importance in care in adult intensive care units. This study adds to the growing body of literature emphasizing family nursing practice and family importance in care. To the best of our knowledge, this was the rst study to report on the family nursing practice and nurses' attitude towards family importance in care in adult ICUs of Uganda. This could be an initial step that avails evidence needed to advocate for more family centeredness of care and policy.

Design
A cross-sectional design using a descriptive-correlational approach was adopted.

Participants
The study population composed of nurses who have worked in ICU for more than 6 months. Census sampling was used to recruit nursing staff. A minimum sample of 92 nurses was required to have a representative sample according to Krejcie and Morgan's table (Krejcie & Morgan, 1970). Totally, 116 eligible nurses participated in the study.

Procedure
For data gathering, information about the study and an inviting noti cation to participate was sent to the eligible ICU staff in all 13 hospitals with functional intensive care units in Uganda. Participation in the study was entirely voluntary. After voluntarily signing the written informed consent form, the participants could then complete the self-administered questionnaires. Participants chose to complete the questionnaires either using paper and pencil format or online. Con dentiality of personal data was maintained. Data was stored in a database without identi ers and was not shared with any person outside the research group. Data collection was carried out from March to April 2019.

Research Instruments
Two tools were used for data collection in this study, these included theFamily Nursing Practice Scale . The tool has good psychometric properties with an internal constancy of α = 0.88. In our study,the internal consistency of the FINC-NA scale was assessed through the Cronbach's alpha coe cient, obtaining an α of 0.864. The questionnaires which were used in this study were in English that is compatible with the o cial language of the participants.

Ethical Considerations
Ethical approval was sought from the Ethics Committee of Tehran University of Medical Sciences (IR.TUMS.FNM.REC.1397.197) which funded and supported the study and the Research and Ethics Committee of Clarke International University, Uganda (UG-REC-015) were the study took place. Informed consent, voluntary participation and con dentiality were observed at all times. All potential participants were given detailed, written information about the purpose of the study and the data collection procedure using an information sheet. Data was stored without personal identi ers to ensure anonymity.

Data analysis
Data analysis was done using SPSS software (version 16; SPSS Inc., Chicago, IL, USA). Descriptive statistics including means, standard deviations, and frequency distributions were used for description of the study population and the main variables (FNPS and FINC-NA). Pearson's correlational coe cient was used to assess the correlation between FNPS and FINC-NA, after approving normality with Kolmogorov-Smirnov test (P>0.05).. To compare differences in attitude and family nursing practice according to background variables, Student t-test and ANOVA were used. The signi cance level was set at P<0.05.

Results
A total of 116 participants fully completed the study. The mean age of the respondents was 29.4 (SD = 3.9). More than half of the sample was female. The mean working experience was 6 years (SD = 3.4) and the mean ICU experience of the respondents was 3.5 years (SD = 2.6). Comparison of education level of the sample showed most respondents had attained a nursing diploma as their highest education (52.6%). Most respondents were working in general ICUs (62.1%) followed by those who worked in specialist medical, surgical and cardiac ICUs. All nurses worked in rotating shifts (morning, evening and night). Most nurses had never had experience of a loved one admitted in ICU and almost all nurses (90.5%) had never had any form of training, courses or conferences in family nursing.

Family nursing practice
Insight into mean subscale scores on the FNP scale for the sample is shown in Table II. The mean FNP score was 38.7 (SD = 12.7). Descriptive analyses of FNP showed that the item "I support the family when they express their feelings" had the highest mean score, whilst the item "I try to create opportunities to converse with the family" had the least mean score (Table I). The mean score of the total FINC-NA Scale was 90.6 (SD = 14.7), the total FINC-NA scores obtained varied from 74 to 117 (Table III). Comparative analyses showed that there was a statistically signi cant positive correlation between FNPS and FINC-NA (r = 0.6, p<0.01). Emphasis on a collaborative relationship between healthcare providers, patient and their family is rooted in the family nursing. The patient and their family must receive support from healthcare providers, relatives and friends during their stay and after discharge from the hospital. However, this is might not always be the case. Other subscales FNPS revealed nurses had the low average scores on the subscale "awareness of what the family considers to be important in their interactions". This could partly be attributed to the busy schedules and due to under sta ng. This makes nurses to be overwhelmed by responsibilities of caring for patient and leaves them with less or no time for caring for patients' family in ICU. Nurses need to interact with the patients' family from the rst encounter with the patient. This can help in involving and supporting the family while being aware of who they are and their needs.

Limitations of the study
In this study, practice of nurses in family care was assessed through self-report. Although we minimized such limitation by requesting respondents to answer the questionnaire with utmost honesty based on reality, it is recommended to measure FNP through performance assessment methods in another study to minimize the possible bias from self-rating of one's own behaviors.

Strengths of the study
The results of the study must be interpreted with respect to its strengths. A representative sample from different hospitals and census sampling used in this study makes the generalisability of the ndings reliable and could give a good interpretation of the data in the perspective of FNP and FINC-NA in critical care settings of Uganda. It is hoped that the ndings will be a useful addition to the growing body of literature highlighting FNP and FINC-NA in adult intensive care units.

Recommendations
Interventions to improve family nursing practice in critical care settings be investigated in other studies. Such interventions should integrate different strategies aiming at integration of the clinical staff and patients' family members to effectively meet the families' needs during admission and following discharge from ICU. Including family nursing with its components for critical care in curriculum of nursing can develop more positive attitudes, con dence and motivate nursing students to effectively respond to patients' relatives needs in the future. Continuous professional development trainings including all aspects of the family nursing should be carried out for ICU nurses. Development of o cial family nursing position statements in Ugandan, as well as International nursing and medical organisations should be considered in order to clarify the current national and international recommendations on family nursing practice.

Conclusion
This study, as the rst study with regard to family care in Uganda, revealed that most nurses had positive attitude towards family importance in care however, in most instances their practice of family nursing is moderate. Comparative analyses identi ed that there is a positive correlation between nurses' attitude towards family importance in care and family nursing practice, by emphasizing on involvement of families in care through effective training courses, there is good prospect for improvement of nursing practice about families. It is vitally necessary in sub-Saharan countries.