Journal of Advanced Nursing, 1999, 29(5), 1178±1187 Nursing theory and concept development or analysis

Family-centred care: a concept analysis

Kay Hutch®eld BA (Hons) RGN RSCN ONC DipN RCNT
Senior Lecturer, Nursing Studies, Canterbury Christ Church College,
Canterbury, Kent, England

Accepted for publication 5 June 1998

HUTCHFIELD K. (1999) Journal of Advanced Nursing 29(5), 1178±1187

Family-centered care: a concept analysis
Family-centred care would seem to be a central element of children's nursing,
but there is no consensus about its meaning. This paper uses a combination of
Rodgers' evolutionary model of concept analysis and Schwartz-Barcott and
Kim's hybrid model of concept development to facilitate a dispositional
approach to analysing this concept. Data from a qualitative survey undertaken
during 1994/1995 was used in conjunction with data obtained through a
questionnaire, to provide the ®eld-work element for the process of analysis. The
process resulted in the identi®cation of the antecedents and attributes of family-
centred care, and the identi®cation of a lack of clarity related to the conse-
quences of family-centred care. Two alternative models of family-centred care
emerged, both of which demonstrate strong associations with the concepts of
partnership with parents, parental participation and care by parents. The paper
does not conclude with any de®nition of family-centred care, but rather
explores its usefulness in practice and considers how the concept might be
operationalized. The tentative proposals for a hierarchy of family-centred care
will require exploration, testing and evaluation by practitioners in the real
world of children's nursing.

Keywords: concept analysis, concept development, family-centred care,

parental involvement, parental participation, partnership

and the Audit Commission (1993) promote family-centred

INTRODUCTION
Ambiguity and confusion about elements which are cen-
tral to nursing, present a signi®cant barrier to the devel-
opment of nursing knowledge and practice (Rodgers
1993a). Seeking clari®cation of these central elements
would not only generate descriptions and de®nitions but
could also explore meanings, and promote theory devel-
opment in nursing (Rodgers 1993a, Kitson 1993).
Family-centred care
Family-centred care would seem to be a central element of
children's nursing (Nethercott 1993, Evans 1994). Docu-
ments published by the Department of Health (DoH 1991)
care as the underpinning philosophy for the care of sick
children, and yet offer little insight into what the term
actually means. It would, therefore, seem important to
explore this phenomenon in an attempt to clarify its
nature.
Campbell & Summersgill (1993) suggest there is no
consensus about the meaning of family-centred care,
whilst Darbyshire (1993) considers family-centred care
another one of children's nursing's `amorphous terms',
and suggests that there is a risk that it may be applied
uncritically to all situations involving sick children.
Concept analysis

Correspondence: Kay Hutch®eld, 22 Station Road, Cuxton, Rochester, Kitson (1993) proposes that talking about concepts helps
Kent ME2 1AB, England bring them into conscious thought and reduces the risk of

1178 Ó 1999 Blackwell Science Ltd

Nursing theory and concept development or analysis
them being used unthinkingly. Concept analysis offers a
vehicle for identifying the shared meaning of concepts
which is imaginative, and has both logical and psycholog-
ical dimensions. This implies that concept analysis is not
just concerned with discovering de®nitions and meanings,
but also explaining why those meanings have developed.
However, it could be argued that family-centred care is
not a concept, but a construct, a proposition or even level
one practice theory (Dickoff et al. 1968). Nevertheless,
other authors have used concept analysis to explore the
notion of family-centred care Nethercott 1993, Bradley
1996) and, therefore, for the purpose of this paper, family-
centred care will be considered a concept, whilst ac-
knowledging that this view may be challenged.
Models of concept analysis
Rodgers (1993b) suggests that in the past an essentialist
approach has been adopted to concept analysis: this
approach searches for boundaries that delineate the
concept so that it can be applied in the same way no
matter what the context. She suggests that a dispositional
approach is preferable as it searchers for meanings and
common usage, and acknowledges concepts as dynamic
and changing over time, rather than ®nite (Rodgers 1993a).
The dispositional approach seemed to be appropriate
for family-centred care, because there is evidence to
suggest that the concept has developed over time, and
has been in¯uenced by the changing context of the care of
sick children (Coyne 1996, Bradley 1996). The view that
concepts will change over time means that rede®nition
becomes essential if the concept is to remain useful,
applicable and effective (Rodgers 1993a).
Rodgers' evolutionary model describes eight steps in the
process of concept analysis that offers a dispositional
approach (Rodgers 1993b). However, it does not clearly
identify the ®eld-work that is an important element of the
process. For this reason the model has been used in
conjunction with the Hybrid Model of Concept Develop-
ment (Schwartz-Barcott & Kim 1993) as it clearly identi®es
the ®eld work as a separate entity to the theoretical phase,
and acknowledges the dynamic, developmental nature of
concepts. This also enables the process of analysis to move
from one that is ®nite and results in a de®nition, to one that
is developing and moving towards the development of
practice theory (Dickoff & James 1968, Meleis 1991).
The ®nal step in the theoretical phase of the hybrid
model is the development of a tentative working de®nition
(Schwartz-Barcott & Kim 1993). Instead this element will
be replaced by identifying model cases; the exploration of
attributes, antecedents and consequences and the identi-
®cation of surrogate and related terms that emerge as a
result of the ®eld-work and literature review. This has
resulted in the development of an eclectic mode (Figure 1)
that would seem to be more congruous with an approach
that is seeking meaning rather than de®nition, and re¯ects
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(5), 1178±1187
Family-centred care
Theoretical phase
Field-work phase
Selecting a concept
1
1 Setting the stage &
2 Searching the literature negotiating entry
2 Selecting the cases
Initial analytical phase
3 Collecting and managing data
4 Dealing with meaning and measurement
5 Analysing data
5 Identifying model case
Final analytical phase
6 Weighing up and interpreting results
8 Identify implications for further enquiry and
development
8 Writing up the findings
Figure 1 An analytical framework that combines Rodger's Model
of Concept Analysis and Schwartz-Barcott & Kim's Hybrid Model
of Concept Development.
the concept development stage of theory development
described by Meleis (1991).
Both models identify the theoretical and ®eldwork stage
as being undertaken simultaneously. However, for clarity
of presentation the elements of the two stages will be
discussed consecutively rather than in the chronological
order in which they were undertaken.
Concept analysis of family-centred care
The theoretical stage begins with selecting the concept.
The relevance of the concept of family-centred care to
children's nursing has already been identi®ed. However,
the subsequent review of the literature will not only
further explore the meaning of family-centred care, but
also its usefulness, applicability and effectiveness as a key
concept in children's nursing. This is an important aspect
of the dispositional approach to concept analysis that
ensures that the analysis has some purpose that relates to
practice (Rodgers 1993b).
LITERATURE REVIEW
Both Rodgers (1993a) and Schwartz-Barcott & Kim (1993)
emphasize the need to search the literature extensively.
Rodgers' approach is primarily concerned with the extent
and comprehensive nature of the literature review in order
to demonstrate a rigorous approach and reduce researcher
bias (Rodgers 1993b). Once the literature has been gath-
ered the focus is on identifying the essential nature or
`essence' of the concept in the form of attributes. The
attributes are not dictionary de®nitions, but represent the
`real' de®nition of the concept.
1179
K. Hutch®eld
Schwartz-Barcott & Kim (1993), however, use the liter-
ature to explore the relative strengths and weaknesses of
the various de®nitions offered in order to produce a
tentative de®nition. This appears to re¯ect the labelling
stage of theory development described by Meleis (1991).
Although the approach taken to the literature review
does re¯ect both models no attempt was made to produce
a de®nition. Rodgers' approach was used to try and
identify key characteristics of the concept that emerged
from the literature (Rodgers 1993a).
An extensive review of the literature was undertaken
which included literature from the United States of
America (USA) and the United Kingdom (UK). The
literature from the USA demonstrated a much clearer
conceptualization of family-centred care than that of the
UK.
The majority of the reviewed literature from the USA
made reference to the work of Shelton et al. (1987). This
seems to be viewed as a seminal work which marked a
`new era' for family-centred care (Trivette et al. 1993).
Shelton et al. (1987) developed a comprehensive frame-
work for offering family-centred care to children.
This framework was developed in collaboration with
parents to provide family-centred care to families with
children who had special educational needs, and has been
adapted by others to provide the framework of care for
critically and chronically ill children Trivette et al. 1993,
Ahmann 1994, Bond et al. 1994, Letourneau & Elliot
1996). Ahmann (1994) combined the framework with a
communication model to facilitate the collaborative rela-
tionship between nurse and parent.
Recently the framework has been revised and some
minor adjustment made in the light of discussions be-
tween families and professionals, and the elements pre-
sented in order of importance (Shelton & Smith Stepanek
1995, Figure 2).
Within this framework family-centred care is seen as a
philosophy of care that makes a difference, where family
and professional partnership is evident, and that promotes
· Respect for the family as the constant in the child's life.
· Family/professional collaboration.
· Exchanging complete and unbiased information.
· Recognition and honouring the cultural diversity.
· Recognizing and respecting different methods of coping.
· Developmental, educational, emotional, environmental,
and ®nancial supports to meet the diverse needs of the
family.
· Family-to-family support and networking.
· Flexible, accessible and comprehensive hospital, home and
community service and support systems.
· Appreciating families as families and children as children.
Figure 2 Summary of the elements of Shelton's Framework of
Family-Centred Care. (Shelton and Smith Stepanek 1995).
1180 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(5), 1178±1187
normalized patterns of living for the family (Shelton &
Smith Stepanek 1995). Shelton's framework could be said
to represent the attributes of family-centred care. How-
ever, Trivette et al. (1993) suggest that further research
is required into translating Shelton's framework into
`speci®c kinds of practice'. Letourneau & Elliot (1996)
also express a need for more research and suggest that this
should focus on identifying why it appears to be dif®cult
to implement family-centred care in the acute setting. This
could suggest that a framework for family-centred care
developed for one setting (care of children with special
needs) may not be transferable to another (acute setting).
Although some authors (Campbell & Summersgill 1993,
Campbell et al. 1993, Darbyshire 1994) in the UK have
acknowledged the work of Shelton et al. (1987) this work
does not appear to have had the same impact in the UK.
This may be partly explained by the different develop-
ment of family-centred care in the UK where it seems to
have developed primarily in the acute hospital setting.
In the UK Nethercott (1993) undertook a concept anal-
ysis which identi®ed seven key components of family-
centred care, which are summarized in Figure 3. Although
some of the components acknowledge the importance of
viewing the family in context and respecting family
diversity, the majority of the other components appear to
focus on supporting the functional role of the family. It
appears to lack some of the mutuality demonstrated in
Shelton's framework. It does not give any emphasis to the
strengths parents have, for example, as the constant in the
child's life or having speci®c knowledge about their child.
During her analysis Nethercott (1993) identi®ed
differences between parental involvement and parental
participation. The former was seen as a precursor of
family-centred care where the nurse exercises control over
the family involvement, whereas parental participation
was seen to be based on a more collaborative relationship.
Partnership, parental participation and involvement are
concepts that have also been identi®ed by others as
closely associated with family-centred care (Dearmun
· The family must be viewed in its context.
· The roles of individual family members must be evaluated.
· Parents should be enabled to participation in decision-
making.
· The prime carer should be involved in care planning and
evaluating.
· Families should be involved in the technical aspects of
care.
· Usual child care practices promoted in hospital, unless
detrimental to the child.
· The support given to families should continue after
discharge.
Figure 3 Summary of components of family-centred care identi-
®ed by Nethercott (1993).
Nursing theory and concept development or analysis
1992, Stower 1992, Palmer 1993, Gill 1993, Casey 1993,
Evans 1994, Darbyshire 1994, 1995a, 1995b, Coyne 1995).
Recent articles by Bradley (1996) and Coyne (1996)
suggest that family-centred care in the UK has developed
as a direct result of the changing context in which sick
children have been nursed since the 1950s. Bradley (1996)
suggests that change was initially revolutionary following
the recognition of the emotional needs of hospitalized
children. This change has then become a slower evolu-
tionary process in response to the gradual acceptance of
the fact that children bene®t from the presence of their
parents when they are ill. She suggests that the involve-
ment of parents in the care of their children has resulted in
the emergence of the concept of family-centred care. This
view is supported by Coyne's concept analysis of parental
participation (Coyne 1996). She concludes that parental
participation has changed over time, ®rst to partnership
and ®nally to family-centred care.
An interesting perspective is offered by Cahill (1996),
who analysed the concept of patient participation, and
concluded that there is a hierarchical relationship be-
tween involvement, participation and partnership rather
than one concept replacing the previous one. Partnership
has been identi®ed by several authors as a central element
in family-centred care Arango 1990, Casey 1993, Ahmann
1994) with respect, collaboration, negotiation an commu-
nication (Birch 1993, Ahmann 1994) being key elements
in the process.
De®nitions of family-centred care that emerged
from the literature
In other literature reviewed, family-centred care was
described as `an holistic approach' (Stower 1992), a
`philosophy that supports parents in their caring role'
(Gill 1993), a basic/fundamental tenet of paediatric nurs-
ing (Nethercott 1993, Evans 1994), `care-by-parent' (Evans
1994), `parents and professionals collaborating together'
(Odle 1988), `an opportunity for parents to care for their
hospitalised child under supervision' and `maintaining
family roles' (Brunner & Suddarth 1986), `to minimise the
trauma of hospital stay' and to `allow an independence
and quality of life that would otherwise be impossible'
(Robbins 1991), `to incorporate the family into the plan of
care' (DePompei et al. 1994), `to recognise the family as
central in the child's life' and a `partnership that supports
parents in their central caring role' (Ahmann 1994). This
selection of extracts gives some idea of the range of
de®nitions that exist which seem to re¯ect two emerging
views of family-centred care. Some offer an holistic view
of the child and family and represent a description of
family-centred care which is grounded in respect for and
co-operation with the family. Within this view the nurse is
an equal partner and the facilitator of care. The other
approach appears more functional and less collaborative,
with the nurse taking the role of gatekeeper and dominant
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(5), 1178±1187
Family-centred care
player in the partnership, deciding what care the parent
can participate in, and perhaps limiting the ability of the
family to regain control of their situation (Baker 1995).
These two alternative models of family-centred care that
emerge from the UK literature offer a linear or hierarchical
conceptualization of family-centred care within the acute
care setting. Both acknowledge the strong relationship
between parental involvement, parental participation,
partnership and family-centred care.
Surrogate and related terms
This exploration of the literature has incorporated the
initial analytical phase, and as a result of this process it is
possible to identify surrogate and related terms. In the
literature reviewed parental participation, shared care
and partnership with parents appear to be terms synon-
ymous with family-centred care (Evans 1992), and re-
search in areas such as resident parents, nursing attitudes
to parent participation (Gill 1987, 1993, Dearmun 1992,
Darbyshire 1994), and care by parents (Sainsbury et al.
1986, Cleary 1992) contribute to the idea of what family-
centred care is but do not offer a comprehensive de®ni-
tion.
Antecedents and consequences
Rodgers (1993b) also suggests that the literature review
should result in the identi®cation of antecedents and
consequences, both of which contribute to the clari®cation
of the concept. The antecedents that emerge from the
literature appear to be linked with the presence of parents
on the ward and their willingness to be involved in the
care of their child (Darbyshire 1993), the willingness of the
staff to collaborate with parents (Brown & Ritchie 1990),
and the provision of facilities for parents to be resident
with their child.
At this stage the consequences seem to be based on the
assumption that both children and families will bene®t
from this approach (DoH 1991, Audit Commission 1993).
Although there is evidence to suggest that these assump-
tions are true, research by Darbyshire (1994) would
suggest that caring for their sick child in public can be
extremely stressful for parents. Further research into the
bene®ts of the approach to children and parents would be
bene®cial, especially if it helped to identify those children
and families who do not appear to bene®t from this
approach.
In addition, little or no thought has been given to the
resources required to support such an approach. Bishop
(1988) identi®ed adequate time for communication as an
essential precursor of the family-centred care in order to
facilitate the teaching and supportive role of the nurse.
Other authors have suggested that children's nurses need
particular knowledge, skills and experience in order to
adequately implement family-centred care, which do not
appear to have been given adequate consideration
1181
K. Hutch®eld
(Nethercott 1993, Baker 1995). It may be that the conse-
quences of family-centred care may become clearer as the
concept itself emerges from the confusion of its past.
The ®eld-work phase
Rodgers (1993b) suggests that the next stage in the process
is to identify model, contrary and borderline cases in order
to further assist with the identi®cation of attributes. This
element has been incorporated into the ®eld-work phase of
the eclectic model.
Rodgers (1993) does not identify ®eld-work as part of
her data collection process. Schwartz-Barcott & Kim
(1993), however, consider ®eld-work an essential element
in concept development and use qualitative data gained
by participant observation and in-depth interviews to
develop insight into the nature of the concept. Time
restraints prevented any data gathering by the process of
participant observation; however, the ®eld-work under-
taken yielded data from three separate sources:
semi-structured interviews, questionnaires, and the
identi®cation of model, borderline and contrary cases.
THE STUDY
Interviews
The ®rst source of data resulted from a unpublished
qualitative survey of children's nurses' views on the
nature of family-centred care undertaken during 1994/
1995. The data were collected from 24 children's nurses
using semi-structured interviews. Analysis of the data led
to the identi®cation of themes concerned with:
 the central importance of the well-being of the child;
 respect for parents;
 the changing nature of child nursing;
 the presence of parents on the ward staying with their
children;
 the provision of an appropriate environment, facilities
and resources to support parents;
 the maintenance of the child's routine;
 involving the parents in care/partnership with parents;
 involving parents in decision making;
 honest and open communication;
 concern for the whole family; and
 negotiating care.
Some of these themes suggest that practitioners concur
with the view that family-centred care is evolutionary in
nature. Other themes evident in the literature are also
re¯ected in the themes that emerged from the data. Key
elements of family-centred care identi®ed included respect
for parents and a concern for family well-being, collabora-
tive working in the form of a partnership, shared decision
making and effective communication. Involving the par-
ents in the care of their child was spoken of by all the
1182 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(5), 1178±1187
practitioners interviewed. For some it represented a purely
functional role, whilst others seemed to view it as a way of
helping parents cope with a stressful situation by enabling
them to regain some control over what was happening.
Further clari®cation of the antecedents was also ob-
tained as a result of considering some of the theoretical
categories. Facilities were seen as a necessary requirement
for helping parents care for their children, and other
resources such as adequate time to develop a relationship
with families were also identi®ed. In addition the will-
ingness of parents to become involved in their child's
care, the degree to which parents felt welcomed on the
ward and the willingness of the staff to share the care and
decision making with the child and family, seemed
important antecedents.
This study was supervized by an experienced research-
er; however, the small size of the sample and the non-
probability approach to sampling used suggests that the
results cannot be generalized.
As there appeared to be some similarities between the
literature reviewed and the data gathered by interview, a
questionnaire was developed in an attempt to validate the
®ndings.
Questionnaire
The questionnaire contained 24 statements re¯ecting the
nature of family-centred care. Six statements represented
the underpinning beliefs and values of family-centred
care, for example `separation of children from their
parents can result in emotional trauma'. Six further
statements represented desired professional attitudes,
such as `the family is respected as a constant in the
child's life'. The ®nal 12 statements were concerned with
professional behaviour such as `collaboration in decision
making'. The respondents were asked to indicate whether
they agreed, disagreed or were unsure that the statements
re¯ected central elements of family-centred care. Space
was also provided for respondents to make additional
comments if they wished.
The participants for the questionnaire were chosen
because they were conveniently available. This type of
non-probability sampling is criticized for it's potential for
bias and erroneous ®ndings; however, time and resources
were unavailable to facilitate probability sampling that
would have offered a more rigorous approach to sampling
(Polit & Hungler 1993).
The questionnaires were distributed to two different
groups of children's nurses. The ®rst group comprised 16
experienced, quali®ed children's nurses undertaking a
master's programme in child health nursing. These prac-
titioners came from a wide geographical area of England
and Scotland, and from diverse areas of practice including
community paediatric care, palliative care, intensive care,
general paediatric care, paediatric management and nurse
Nursing theory and concept development or analysis
education. The second group were 17 pre-registration
students from a college of higher education, and were at
the beginning of their child nursing branch programme.
Results
No negative responses were recorded on the question-
naire; however, some respondents were unsure whether
all the statements represented central elements of family-
centred care (Figure 4). The majority of the group of
quali®ed nurses agreed with the statements identi®ed.
The greatest area of ambivalence was associated with
statements relating to `support provided that meets the
needs of the whole family', and `access to additional
information facilitated'. Additional comments from ®ve
respondents suggested that family-centred care is an
idealistic notion. One comment suggested that on a busy
general children's ward perhaps family involvement
rather than family-centred care is all that is practised.
Results from the student nurses were very different,
with 15 statements registering three or more `unsure'
scores (Figure 4). The greatest area of ambivalence fell
within the section of underpinning beliefs and values.
They were particularly unsure whether: `separation
of children from their parents can result in emotional
trauma' (statement 1); `children need to be cared for in the
context of their family' (statement 4), and `the family
provides an effective support system for the child' (state-
ment 5). It is not possible to draw any conclusions from
16
14
12
Number unsure
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Statement number
Figure 4 Number of unsure statements.
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(5), 1178±1187
Family-centred care
these results other than to suggest that there may be a
difference between student and quali®ed nurses' percep-
tions of family-centred care. This possibility was high-
lighted by Baker (1995) who suggests that students appear
to be reluctant to involve parents in care, share informa-
tion and teach skills to parents. This may be because they
need to develop practice skills themselves and have not
the con®dence and experience to share information and
teach the parents. It may therefore be necessary to con-
sider what role it is appropriate for students to play with
families who are being offered family-centred care.
Model, contrary and borderline cases
Rodgers (1993b) suggests that the identi®cation of model,
contrary and borderline cases from personal experience is
a useful way of identifying the essence of a concept. Both
groups were asked to identify model, borderline and
contrary cases in a context where clari®cation of the
terminology could be sought. The results from both groups
were similar.
Model cases included examples where:
 parents were facilitated to give physical and/or techni-
cal care;
 the involvement of parents was voluntary and negoti-
ated;
 efforts were made to promote and maintain family roles
and relationships;
 the parents' expert knowledge of their child was
respected; and
1183
K. Hutch®eld
 information was communicated effectively.
Borderline cases appeared to present dif®culties for the
respondents, and the value of the data is dif®cult to
evaluate; however, contrary cases provided more depth of
insight into aspects that are not considered family-centred
care (Figure 5).
The majority of these examples appear to reinforce the
centrality of attributes such as communication, a non-
judgemental approach to families, respect for parent's
knowledge of their child and the important role they play
in the child's life. It also reinforces the fact that family
involvement must be in the child's best interest
and demonstrates the importance of time to develop a
relationship between the nurse and the family. This
relationship enables the nurse to gain insight into the
problems and priorities of the family that facilitates the
development of an appropriate plan of care for the child.
THE FINAL ANALYTICAL STAGE
This is the stage in which all the information is brought
together in an attempt to identify the meanings it contains.
It then became possible to begin to distinguish the
antecedents, the attributes and consequences of family-
centred care.
The antecedents that began to emerge from the analysis
are identi®ed in Figure 6. It would seem that the attitude
of nurses and the provision of adequate resources are of
primary importance if family-centred care is to be suc-
cessfully implemented.
Exploring the antecedents appeared to shed some light
on the problems of implementing family-centred care that
were identi®ed within the literature and by some practi-
tioners. This relates particularly to issues such as the time
required to support parents and build a relationship with
families. It could be suggested that reports (DoH 1991,
· Lack of awareness of the information needs of the family.
· Poor communication between nurse and family.
· Lack of insight into the impact of the illness on the family,
particularly siblings.
· Lack of respect for the parents' knowledge of the child.
· A lack of family involvement because the nurse is giving all
the care.
· Labelling and making judgements about families.
· Lack of time to listen to family concerns not directly related
to the ill child.
· Not viewing the child as part of a family.
· Denying child access to his parents.
· Where disagreement about care exists between family and
professional.
· Where child abuse is suspected.
Figure 5 Situations identi®ed as illustrating contrary cases.
1184 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(5), 1178±1187
· It must be in the child's best interests to have the child's
family involved in its care.
· Parents must want to be involved in the care of their sick
child.
· Nurses must be willing to share the care of the sick child
with his family.
· Parents/family must be allowed open access to their
children and be resident with them if they wish.
· Nurses must be prepared to develop a relationship with the
family and collaborate with them.
· Nurses need to be suf®ciently skilled and experienced
themselves so they can adequately support, teach and
empower families.
· Suf®cient time must be available to identify the concerns of
the family.
· The climate of the ward should make families feel
welcome.
· Facilities must be available for parents and families staying
with or visiting their sick child.
Figure 6 Antecedents of family-centred care.
Audit Commission 1993) that have recommended the use
of family-centred care when caring for sick children, have
not acknowledged this aspect of the resource implications.
The most important antecedent of family-centred care
seemed to be that it must be in the child's best interest to be
cared for by their family. If it is demonstrable that it is not in
the child's best interest then family-centred care may not be
· A relationship exists between family and professional that
is not-judgemental and based on honest and open commu-
nication.
· The family is respected for the knowledge they have of their
child, and as a constant in their child's life.
· The diversity of family life is respected and families are not
made to conform to socially constructed norms of institu-
tions.
· Information is given and received in a way that facilitates
informed decision making for families and professionals.
· Parents are involved in decisions that are made about their
child's care.
· There is evidence of communication, co-operation and
collaboration between family and professional.
· Involvement and participation by the parents in the
physical aspects of the care of the child are voluntary and
negotiated.
· The professional acts in such a way as to promote normal
family functioning and autonomy.
· The nurse is concerned with the well-being of the whole
family, and acknowledges that the ill child may not be the
only concern of the family.
· Parents and families are provided with physical, emotional
and teaching support in their caring role.
Figure 7 Attributes of family-centred care.
Nursing theory and concept development or analysis Family-centred care

Family-centred care
Relationship: Mutual respect & involves many family members FCC: Parent-led
Parents & family: Extensive knowledge of child's illness and treatment acknowledged
Parents' nursing and technical skill respected
Nurses role: Consultant/counsellor Parents' role: Expert in all aspects of care of their child
Communication: Dialogue; families involved in policy making

Partnership with parents

Relationship: Equal status Communication: Negotiation of roles
Concerned with family well-being Identi®cation of support needs
Parents & family: Parents empowered to give care Parents' role: Primary care-givers including n/c
Nurse's role: Supporter, advisor and facilitator
Acknowledges ill child not only concern of family
Ensures parents get breaks, etc.
Partnership: Acknowledges parents' equal status as care-givers; parents knowledgeable & skillful

Parental participation
Relationship: Rapport established Communication: Sharing of knowledge
Other family members involved Reinforcing of importance of parent's role
Collaborative in nature Parents' role: Participate in normal care-giving
Parents & family: Strengths of family acknowledged Undertake nursing care if they wish
Participation in care: Nurse's role: Responsible for ensuring all care given
Negotiated and voluntary Undertakes care parents do not want to give
Nurse tends to be gatekeeper Teaches parents how to give care

Parental involvement
Relationship: Meet as strangers Communication: Open and honest
Interaction primarily with parent and child Emphasis on information giving
Likely to be nurse led Information written and verbal
Requests for information addressed
Parents & family: Respected as constant in child's life Parental role: Advocate for child
knowledge of their child respected Emotional support for the child
Diversity of family life accepted Nurse's role: Gives nursing care
Helps parents give normal care
Advocate for family
Involving in care: Parents feel involved in what is happening to their child
Parents helped to provide emotional support and care for their child
Parents' normal roles maintained where appropriate for child and parents

Figure 8 A hierarchy of family-centred care.

an appropriate model. The situation most commonly iden-
ti®ed as typifying this case is that of non-accidental injury,
although it must be acknowledged that this represents only
a small number of children admitted to hospital.
Attributes of family-centred care
The attributes of family-centred care that have emerged
from the analysis of the literature and the data are
identi®ed in Figure 7. There appears to be agreement
across the literature and ®eldwork that the relationship
between the family and the nurse is central to family-
centred care, and is based on respect for the family and
honest and open communication. The data obtained from
the ®eldwork, however, suggest that nurses are unsure
whether they are required to facilitate the acquisition of
further information or have time to help families with
problems not directly concerned with the sick child.
It is clear from the literature and ®eld-work that co-
operation, collaboration and negotiated care are not
always evident in the care provided to sick children and
their families, and this was illustrated in some of the
contrary cases described. This implies that there may be
problems implementing some aspects of family-centred
care that warrant further study.
Another area of dif®culty identi®ed in the ®eldwork was
the provision of adequate support for parents in their
caring role. Ensuring parents had suf®cient rest was seen
as problematic as parents were often reluctant to leave
their sick child, and the nurses were unable to offer them
the one-to-one care the parents could provide.

Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(5), 1178±1187 1185
K. Hutch®eld
THE NEXT STAGE: FURTHER ENQUIRY
AND DEVELOPMENT
Identifying implications for further enquiry and develop-
ment is the next stage in the process. Although the
evolutionary nature of the concept of family-centred care
has been identi®ed it would appear that it has focused
primarily on children who are accompanied and/or visit-
ed by their parents. Progress has been reactive to the
changing context of child care and the acknowledgement
of the emotional and developmental needs of the hospi-
talized child. However, development appears to have been
on one dimension with no real advances made in the care
of the unaccompanied child or the child whose best
interest is not served by being cared for by his family.
Problems identi®ed by Darbyshire (1994) and experienced
by parents and families caring for their children in
hospital require further debate concerning the positive
and negative aspects of family-centred care. This might
also lead to clari®cation of how children's nurses should
go about involving parents in the care of their child, and
how true collaboration and partnership can be achieved.
It would appear that attempts are being made to apply
family-centred care in situations where it will not work
because it is inappropriate or where the necessary re-
sources do not exist. This creates the potential for the
development of unnecessary stress for children, parents,
families and professionals.
Although the ®nal step of the process of analysis and
development is the writing up it also appears to be the
beginning of the next stage. It does not seem suf®cient to
stop the process here. If the concept is to have meaning then
there must be some discussion that involves its usefulness
in practice. In order to achieve this the concept needs to be
operationalized in order that practitioners will know the
concept when they experience it in operation (Norris 1982).
Cahill's concept of a hierarchy that begins with involve-
ment and progresses through participation to partnership
(Cahill 1996), and the qualitative data collected by the
questionnaires have provided a springboard that family-
centred care may in fact be a hierarchy which begins with
parental involvement and culminates in family-centred
care. Family-centred care in its fullest sense is therefore
only implemented in some cases.
This next development could be considered the begin-
ning of a theory of family-centred care (Figure 8) that
would need to be implemented in practice and most
importantly evaluated (King et al. 1997) and developed by
practitioners and families to clarify and develop a concept
that still appears to have considerable relevance to the
care of sick children.
It is a framework that could be applied to all children
and families, even if child abuse is suspected. The `lowest
level' could be said to represent the minimum that any
family could expect of the nursing profession.
1186 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(5), 1178±1187
This concept analysis, therefore, has no conclusion, but
rather another beginning that must be tested and devel-
oped in the real world in order to move the concept of
family-centred care forward to contribute to the body of
knowledge that constitutes children's nursing.
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