Family-Centered Care in Pediatrics

Chapter 1: Introduction To The Study

Introduction

In order to achieve better patient experience and health outcomes, it is well acknowledged that it is necessary to involve and consider the needs of patients and their families (Entwistle, 2009). This aspect should particularly ensure that health care provided is in accordance with the children’s and the families’ needs and preferences. The realization of this concept saw the need to move away from nursing care systems underpinned by the traditional biomedical models of care, and towards the development of the patient-centred models of care (Alisic et al., 2014). The family- centred care (FCC) is one such model. It has been widely explored and found to focus on the aspect of paediatric nursing. The family centred care model has been underlined by various principles. The main principles include the involvement and engagement of the family in providing care for their children (Shields, 2015). Within the context of child healthcare, FCC underpins the philosophy of paediatric nursing, and provides a means for the involvement of the family in the care of their children (Smith et al. 2015). The hospitalization of a child is associated with emotional trauma and anxieties for the affected families. Hospitalization results in separation from parents and home environment which may lead to anxieties and stressful episodes for the family. Notably, parents are experts in regards to the care of their children, and therefore it is important that the involvement of the parents, the information provided and their viewpoints should be taken into consideration in clinical decision-making in managing their children’s conditions (Smith et al. 2015). Parental involvement and the concept of partnership are integral to paediatric health. These two factors are core principles of the FCC model and always serve towards recognizing the health care needs the child and the family. Thus, the FCC concept emphasizes that the sick child and the entire family receive attention and support during hospitalization of the child. Despite the fact that the concept of FCC in child care is widely endorsed in the UK by clinical organizations such as the Action for Sick Children and the Paediatric Nursing Associations of Europe, it has been asserted that there are several challenges to its implementation (Ramezani et al. 2014). It has also been contended that over the past years, however much these models are being promoted, they are rarely applied in real practice on a day to day basis (Coyne, 2013). Parents’ involvement in the care of their hospitalized children is acknowledged as a key aspect to improved paediatric health outcomes; however Vasli and Salsali (2014) assert that this principle is among the concepts that have no clear consensus. This study therefore aims to explore this element of family-centred care and parental involvement in children hospital care.

Background of the Study

Family-centred care is a context-appropriate service approach to care referring to a patient-centric view of the patient-healthcare professional relationship (Alisic et al., 2014). Conceptually, FCC has evolved as a philosophy of care, which highly promotes the efficient relationship between families, patients and the service providers and provides support to this collaboration through certain practices and principles. The Family Centred Care concept dates back to the 20th century, the concept began gaining momentum largely through the advocacy led by parents of children with special health care needs (CSHCN) in the 1980s, and has evolved foundationally from permitting parents visitation of their hospitalized children which in turn ended up promoting parents participation and partnership with health professionals in the decision making about the care of their children in hospital settings (Harrison, 2010). Children and their families are provided for the basic form of care through the concept of FCC in paediatric nursing (Smith et al. 2015). According to Ramezani et al. (2014), FCC is considered the gold standard of care in paediatrics. Smith et al. (2015) maintained that working effectively with families to enhance the care of children is central to many organizations that support health professionals working with children and families. Several definitions of Family Centred Care have been provided in literature, so it appears that there is no universally agreed definition (Mikkelsen, 2011; Kuo, 2012; Richards et al. 2017). Richards et al. (2017) asserts that most of the definitions often entail a broad list of principles, which presents difficulty in an attempt to evaluate its effectiveness. According to the Institute for Patient- and Family-Centred Care (IPFCC) family-centred care (FCC) is defined as a method or approach that is essentially grounded in partnerships for mutual benefits among the patients, health care professionals and the patients’ families. This approach or method would particularly include the planning, evaluation and delivery of health care. Within this definition of FCC, the following four core concepts are implied: respecting the status of every party, sharing of information, participating in the decision making processes, and collaborating with each other. FCC is a partnership approach to care that supports the parental role and involvement of parents in the care of their child (Richards et al. 2017). According to Levetown (2008, cited in Richards et al. 2017) FCC enhances effective communication between families and health professionals thereby supporting “much more efficient, effective and empathic paediatric health care”. Richards et al. (2017) affirmed that FCC is recommended as an important key driver towards addressing and controlling family turmoil and improving long-term outcomes of children and their families. Kovacsa et al. (2006) described FCC as an approach that sees every family as unique; it is based on the premise that the family is central in the child's life. The FCC approach acknowledges that the families are the experts with respect to the child's needs and capabilities. The family collaborates with healthcare providers in making informed decisions regarding the provision of care and supports to the child and family. The needs and strengths of all family members are considered with the FCC approach. Family involvement in care has been noted to have a positive impact in maintaining the child health during sickness, as well as strengthening the family bonds. It is a joint partnership between families and healthcare providers in the assessment of the treatment plan and the whole process of recovery of the child. Parents are the child's most trusted and valuable resource; therefore, strategies to support the parents are crucial. According to Smith et al. (2015) many parents living with children with chronic or long term illnesses or conditions grow considerable expertise in the management of the respective conditions of the child, furthermore, they would want to work close to close with the professional care providers so that the outcome may be desirable. Consequently, parents expect care to be achieved through negotiations and that they would be included in the decisions concerning the care of their children. The members of families of the children who are ill should their feelings regarding their children’s hospitalizations so that they may acquire emotional support. Family involvement can assist in assessing the physical conditions ill children and aid the health professional target areas in the family system that might benefit from support. The involvement of family can help to clear up confusions, reduce family anxieties and stress, improving skills of adaptation, and prevent minor disagreements that may arise between the nurses and the family members. In the process of involvement, the nurse or healthcare staff will be able to assess the family's emotional state, as well as assessing the mechanisms involved in coping, the levels of anxiety, the availability of support, and the understanding ability; comprehending information (Brain et al., 2010).

Rationale for the Study

As a multi- faceted model, FCC requires a number of different approaches. These approaches adequately and comprehensively serves the impact and the implementation of the model. The FCC model has been appropriately adopted as a care philosophy used in paediatric nursing. Although supporting the whole concept behind FCC, nurses experience challenges in the implementation of this philosophy in to practice (Harrison, 2010; Ramezani et al. 2014). Similarly, a study by Richards et al. (2017) also reported that clinicians expressed having difficulty in implementing the elements of FCC in the care of the hospitalized children. It was also reported that key principles of underpinning the concept of FCC are not adequately explored in the literature. Appropriate management of hospitalized children is crucial to the recovery process. In contrast to adult patients, management of sick children is unique because they are more often unable to communicate verbally and changes in their health status and other determinants occur more rapidly. In this respect, sick children cannot be viewed and attended to in isolation of their families. Various studies on the health care of sick and hospitalized children emphasize that parental involvement in the health care process is fundamental in the healing process as it helps shape the child’s response to the illness. Their participation in preparing their sick child for hospital experiences is paramount (Hilary and Connie, 2003). The family-centred care as a concept has been analyzed and even widely explored in literature (Hilary & Connie, 2003; Harrison, 2010; Coyne, 2013; Ramezani et al. 2014; Smith et al. 2015) but there is the need to update knowledge and understanding about the application of FCC particularly regarding parent and healthcare professionals’ partnership in child care. Thus, exploring these concepts and their effectiveness in parental involvement in the care of hospitalized children provides an evidence based approach to ensure there is an update in the knowledge and improvement in practice and health care delivery.

Research Questions

The study set out to answer the following questions:

How effective is the family-centred care model of care in facilitating parental involvement for hospitalized children?

What are the challenges faced in the implementation of family centred care in paediatric nursing practice?

Aim and Objectives of the Study

The main aim of this study is to explore the family-centred care models of care and their effectiveness for facilitating parental involvement for hospitalized children.

The following specific objectives were set to address the aim and research question of the study:

To explore the concept and principles of family centred care.

To evaluate the evidence based on the impact of family centred care in facilitating parental involvement in the care of hospitalized children.

To identify and analyze challenges faced in the implementation of family centred care in paediatric nursing practice.

To identify gaps in research and make recommendations for improvements in regards to policy and systems that support the effective implementation of family centred care in paediatric nursing practice.

Dissertation Structure

This dissertation consists of six vividly structured chapters: Chapter one provides for the research rationale, research aims and objectives, and research questions; the second chapter proceeds to provide for the background evidence and literature review about family centred care and parental participation in the care of hospitalized children; the third chapter will introduce research methodology which will include the study design, the search process (inclusion and exclusion criteria), and the search strategy. It also provides for the theoretical framework guiding the study, quality assessment and data analysis; the fourth chapter is the results and the data analysis of the findings that emerged from synthesizing literature will be discussed. In addition, this chapter includes a critical analysis and synthesis of information that was gathered from research studies; the fifth chapter discusses research study findings, generating the themes in the study and addressing the strengths and limitations of the research study; and finally the sixth (Conclusion) chapter provides the suggested recommendations towards addressing any gaps which may have been identified, learning points and a summary to conclude the research study.

CHAPTER 2: LITERATURE REVIEW

In this study, the main methodological approach employed is integrative literature review with the aim of exploring issues relating to family-centred care models and their effectiveness for facilitating parental involvement for hospitalized children. As explained by Whittemore and Knafi (2005), integrative review method is a literature review approach that allows for the combination of diverse methodologies (including experimental and non-experimental research) and has the potential to play a greater role in evidence-based practice for nursing. A review of the literature as pointed out by Cronin, et al. (2008) is an objective and critical analysis of existing evidence and findings from literature relating to a particular subject area. Creswell (2014) described a literature review as searching, pinpointing and summarizing the studies on a particular topic while the process involves the gathering of specific information from numerous sources, and providing a summary from the information gathered. The summarized outcome from the review can then be utilized to inform best practices in clinical decision making, developing appropriate interventions, facilitating change in policy, or assisting in framing a research project or study (Creswell, 2014). Bettany-Saltikov (2012) highlighted some main goals of conducting a literature which include: helping the researcher to focus on areas that have been previously studied on a particular subject matter, it provides a guide about the particular subject matter with respect to identifying the existing research gap, it helps to guide in the justifying the purpose of the study and structuring of the research and it also guides in determining limit for the research and as well as limitation for a chosen study.

CHAPTER THREE: RESEARCH METHODOLOGY

3.1 Literature search

The university databases and other relevant databases were the bases of searching electronically. These electronic searches were conducted to access published literature and materials related to the interested topic. PubMed, CINAHL, EMBASE and The Cochrane Library databases and Google Scholar were searched up to August 2019 for publications in English. Search terms were reported. The related-articles function in PubMed was used and references of retrieved articles were searched manually. Harvard (2007) described literature search as a well-organized and planned process of searching that includes retrieval of all of the published literature on a subject area. The literature search was conducted as a systematic process as suggested by Timmins and McCabe (2005). This process allows for the most effective and efficient identification and selection of relevant and current published research papers to provide evidence on the topic of interest. A range of subject headings, phrases, key words, search terms and full text sentences were used both combine and separately to search the relevant research papers. The PICO framework was employed to breakdown the research question to derive the relevant search terms and keywords. The search terms used include: family-centred care, child hospitalized, parent, parental involvement, collaboration, decision-making, participation. Following the suggestion of Coughlan et al. (2013) the application of Boolean operators (AND, OR, NOT) were used to combine key words in the engine used to search which help to facilitate the narrowing down of the search thus ensuring that only titles which are relevant to the topic were retrieved. Literature retrieved and used to support evidence in this study includes those from the following sources: peer reviewed journals including qualitative and quantitative research and published guidelines.

3.2 Inclusion and exclusion criteria

The inclusion criteria include peer reviewed journals including qualitative, quantitative, or mixed methods studies, related to family-centred models of care for hospitalized children and articles comparing these family-centred models of care with standard or professionally-centred models of care. From 2009 to 2019, wholly published articles in the English language were included for relevance and validity; however, older articles dealing with similar topics or issues were also included. The criteria used for exclusion consists of abstracts only, and studies with focus on other models other than family centred care. These criteria ensured scientific rigor of the study and ensured that only relevant articles returned (Bettany-Saltikov, 2012).

3.3 Search Outcome

The search conducted initially brought back more than 395 articles. These articles cut across all databases. Upon further refining, through the inclusion and exclusion criteria, around 17 articles were available for review. Because of the Critical Appraisal Skills Programme (CASP), however, the number of articles that were included for review resulted to eight. This is the number that resulted from the narrowing down.

3.4 Critical appraisal of studies quality

The research adopted the CASP framework so that the quality of the included studies may be assessed. By using this framework, the validity of the findings, applicability of the concluded information, and credibility of the research is assessed. This framework is easily used and is logical in all aspects of assessment. The studies used were assessed to have achieved the required quality and the research designs, findings and the ethical considerations approved and acknowledged. The resultant results in the reviewed articles have been found to be concise and clear.

3.5 Data extraction and Synthesis of Findings

The research provides for the data extraction table; appendix 1. The table depicted in the appendix includes the name of the author of the reviews, the years of publication, the types of studies, the objectives of the study, the design of research, the considerations as to the ethics and the main achievements or concluded results of the studies (Timmins & McCabe, 2005). The studies included for the review included qualitative, quantitative, or mixed methods research designs and the ranking on the evidence has been presented in the evidence as presented in hierarchical structure; see appendix 2. In clinical nursing research, the ‘gold standard’ is considered to be randomized controlled trials (Moule and Goodman, 2014). This is because these kinds of research inform nursing decision making in the best of qualities. Research, which ultimately focuses on explaining the effects and the causes and the tests of relations, is the quantitative research. This research has its foundation on the post- positivist paradigm (LoBiondo and Haber, 2014). Qualitative research, on the other hand, seeks to explore the phenomena underlined in the experiences of people (Parahoo, 2014). The hierarchy of evidence allows for studies to be graded in regards to their strengths and their types of research designs (Polit and Beck, 2012). The synthesis of the findings in this study has adopted a narrative approach which has focused on interpreting the findings, providing a summary of the evidence and comparing the variances and the characteristics (Moule and Gooman, 2014).

CHAPTER 4: RESULTS

Systematic review of individual studies

In order to examine the impact of the family centered care model on hospitalized children, systematic controlled trials have to be conducted. Shields et al (2011) conducted a study to examine the attitudes to working with children and parents of hospitalized children held by nurses, doctors, allied health and ancillary staff at an Australian children's hospital. In their study, the researchers utilized a validated questionnaire with two scores, one for working with children, one for working with parents, and demographic characteristics, and compared responses. In their this is study, Shields et al (2011) acquired participants through a randomized sample, and compared means of working with children and working with parents scores using the ANOVA test. Additionally, the researchers calculated the mean differences of categories of the demographics using the ANOVA and median test. In a synopsis, Shields et al (2011) expressed that more positive scores were recorded among nurses respondents for working with children compared to the parents. The key determinants of these positive scores recorded included the level of education. The other determinants included the level of position held by the respondents, and the prior experience of the participants working with children for a long time as well as whether the respondents had paediatric qualifications. In this study, Shields et al (2011) concluded that the view of the paediatric health professionals working with children has a more positive outcome than when they working with parents. In this case therefore, the researchers emphasize that utilization of the family-centred care would result in indifferences when working with either children or parents since the FCC model emphasized on whole family as a unit of care.

The study by Coyne (2013) adopted a descriptive and systematic qualitative approach where elements were analyzed based on the grounded theory of research. The collection of data was conducted through individual interviews involving 18 children ages 1-16 years and the similar number of their parents as well as 18 nurses, who were selected from two children’s hospitals and one child in a large general hospital in Ireland following the data analysis. The study identified four key themes that were used to present the results. These themes are; expectations, relying on parents' help, working out roles, and barriers to FCC. Coyne (2013) identified that the nurses unreservedly supported the FCC approach in providing care to the hospitalized children since it benefits the family and the parent’s contribution in care relieves their workload. However, Coyne (2013) contends that minimal evidence was available on the collaboration of negotiation of roles between the parents and nurses leaving parents feeling stressed or abandoned. In regard to the implementation of the FCC, Coyne (2013) found that nurses expressed the busy workload, under-staffing and poor documentations as key contributors to their overreliance on parents in provision of healthcare and inhibited their participation in the negotiation of roles on how to care for the hospitalized children

The study conducted by Molinaro et al. (2017) focused on family care model and its application in the provision of care to children with disabilities. The authors sought to assess the overall perception of FCC provided in an Italian network of 17 rehabilitation services, in light of the perceptions of parents of the children living with cerebral palsy and the healthcare professionals. Furthermore, the study sought to explore the characteristics of the children, service providers and service related characteristics and whether they have and influence on the satisfaction of the Parents regarding the FCC practice. To achieve this, Molinaro et al (2017) relied on the measure of care service delivery (MPOC-20) method for the parents and the measure of care for service providers (MPOC-SP) for the healthcare providers. This was facilitated by the development of an ad hoc information form for collecting information about children, family, service providers and services. Molinaro et al (2017) managed to recruit 382 caregivers or parents and 269 healthcare providers to complete the MPOC questionnaires respectively. The authors report that both the parents and healthcare providers concurred that FCC aided in the formation of positive partnerships and interpersonal sensitivity in the care for the children with cerebral palsy. Among parents, the results indicated that there were key identifiers of the limited parental involvement in the family-centred care and include the advanced maternal age, unemployment, single-parenting, and low socioeconomic status. Additionally, Molinaro et al (2017) identify that high intensity of treatment, inpatient services offered at hospitals during care for the hospitalized children and the primary health settings as well as limited financial resources inhibited the effective implementation of the family centred care for hospitalized children.

From a similar angle, the study conducted by Crespo et al (2016) sought to examine the direct and indirect associations through evaluation of the burden of caregiving, which existed between the parents, family centred care and the quality of life. This study involved 204 parents of the children diagnosed with cancer. In this study, the parents were required to answer delivery of service questionnaire where their perception of FCC was examined in two main domains: family-centred services and provision of general information. Crespo et al (2016) measured the perceptions of caregiving burden, the quality of life and life satisfaction. Furthermore, diagnosis and treatment of the child information was provided by the oncologist. Crespo et al (2016) found that when parents perceive the healthcare of their children as more family-centred, they consequently reported lower caregiving burden furthermore, the study found that FCC services were indirectly linked to quality of life and life satisfaction through the burden of caregiving.

Raiskila et al (2016) conducted a study on the application of family-centred care and sought to describe the presence of the parents and the quality of the family-centred care in light of the views of the mothers, fathers and the nurses in 11 European NICUs.

To achieve this, Raiskila et al (2016) conducted a prospective survey in Finland, Sweden, Norway, Estonia, Spain and Italy. The study measured the perception of the participants on the quality of family centred care using the 8 text-message questions which were sent to the parent’s mobile phones, one question each day, at the period where their infants were hospitalised. On the other hand, the nurses were engaged in answering the corresponding questions from a web-based questionnaire during the 3-month study period. The responses for the questions were rated on a 7-point likert scale and parents who were not present at the hospital unit during the day used the 0 response. From the study, Raiskilla et al (2016) acquired a total of 262 families which were involved in the study. These families had preterm infants that were born before the 35 gestational weeks. Out of these families, the researchers acquires 5045 responses from the mothers while 3971 responses were received from the fathers whereas the nurses gave a total of 11, 132 answers. From their examination, Raiskilla identified that the mothers were present at the hospital during the 92.7% while the fathers were present during 77.9% of the study days. Furthermore, the mother’s rating of the quality of FCC was slightly higher than that of the father’s. Raiskila et al (2016) identify wide variations in the parent’s presence and the quality of the FCC between the units. However, the researchers identified the weakest aspects of the FCC as emotional support, parent’s participation in decision making and the participation of fathers in the infant care.

Uhl et al (2013) conducted a study to describe the experience of the patients providing care to children during the hospitalisation of their children in order to establish strategies that could be adopted to improve the patient and family-care provision in the primary care hospital units. This study was conducted by adopting a two-phase mixed method design where the inpatient hospital experience of the parents of children in the hospital that had been discharged was measured. During the first phase, which the researchers referred to as phase 1, the study was conducted in the semi- structured focus groups. Phase two of the study however entailed parents who completed an inpatient hospital experience survey. The studies were examined and the results identified. The study by Uhl et al (2013) was conducted in south eastern academic children's hospital (178 beds) with 89% of admissions from within the state and the remainder from around the world. The participants included nine parent who were involved in one of the three semi-structured focus groups during the first phase while in phase 2, a total of 2,134 parents were involved and completed the inpatient hospital experience survey. Uhl et al (2013) structured their three focus groups to include three parents while the children’s hospital Boston inpatient experience survey which was designed to measure the perceptions of the parents about care was distributed to the2, 134 patients who participated in the survey. These parents were drawn from all the families whose children were discharged on a 5 month period between March and July 2011. Following their study, Uhl et al (2013) identified three themes in the data from the focus group which include: apprehending the reality, engaging adversity, and advancing forward. The findings from the survey can be organized into eight content areas including care from nurses, care form doctors, working together, child’s experience, hospital environment, child medications (safety), arriving at and leaving the hospital, and overall ratings of the experience.

Sarin and Maria (2019) conducted a qualitative to assess the acceptability family-centred care among providers and family members of neonates. To achieve this, the researchers conducted in-depth interviews among on twelve family members of the neonates who were hospitalised and six providers who were selected on purposive sampling criteria and their perceptions as well as experiences regarding FCC were examined.

From this study, Sarin and Maria (2019) reports that both the family members and service providers in a nutshell expressed positive perception and acceptance of FCC, although this was subject to their competencies and knowledge acquired by parents and caregivers about the essentials care of the new born. The researchers further reported that Family members reported being satisfied with the overall health care experience due to the transparency of care and allowing them to be by their baby’s bedside. However, Sarin and Maria (2019) highlight the infrastructural limitations and lack of facilities at the public hospitals had little impact on the positive perceptions of the parents and the service providers in relation to the use of FCC. Furthermore, the researchers expressed that the service providers viewed the use of family-centred care as a good practice despite the concerns about the sharing of nursery space with parents as well as the expected parent’s constant vigilance when handling their babies, and the need for creating a separate and dedicated nursing staff for family-centred care. Sari and Maria (2019) thus concluded that the providers and the parents of the neonatal children involved in the neonatal care found the FCC to be the acceptable form of care. Furthermore, the researchers expressed that the providers suggested possible solutions to the challenges of FCC including periodic staff sensitization, improved staff performance, and provision of mother-friendly facilities will enhance the application and effective implementation of FCC

In the study conducted by Mallet et al (2018), the researchers focused on the application of family centred care in the paediatric care unit. In their study, the researcher developed a model to enhance the parent’s involvement in the care of their children patients in the PCU. The researchers introduced the concept of parents being invited to be present during the daily morning ward round and proposed a multitude of benefits for patients, parents and staff. To assess these benefits, Mallet et al (2018) developed a questionnaire which was used to assess the attitude of the parents and the staff on the presence of the parents on ward rounds. The participants in this study were composed of the parents and legal guardians of the patients who were hospitalised at the paediatric care unit and who were present for two successive mornings. Data was collected through the use of focused questions which included themes such as communication, empowerment, understanding day plans and whether participants felt it prudential for parents to be invited and remain present during the ward rounds. The researchers equally monitored the length of time of the ward rounds during the two weeks of study.

Mallet et al (2018) reported that the average length of time for the morning ward rounds was 14 minutes per patient. In the study, the researchers managed to get 12 parents who responded to the questionnaire, out of which, 92% strongly in favour of being invited to stay for ward rounds. Additionally, 70 PICU staff members responded to the questionnaire and they included 56 nurses, 5 allied health professionals and 9 doctors out of which, 30% of staff agreed that parents should be invited, 23% were equivocal, and 47% did not agree.

Myrhaug et al (2016) conducted a study to explore the experiences of the parents of children in their preschool with cerebral palsy regarding the level of family centred care using the measure of processes of care (MPOC-20) within hospitals in Norway. The study also sought to examine the relationship between the experiences and the provided daily skills interventions.

In this study, Myrhaug et al (2016) sent a survey to 360 parents of the children in the preschool age with cerebral palsy. Out of which 34% responded. From the scales, high scores were generated on the aspects of respectful and supportive care as well as coordinated and comprehensive care while the aspects of providing general information were the least ranked. The findings of Myrhaug et al (2016) indicated low level of family centredness in primary care settings compared to specialist heath care. Significant positive associations were found between all the five MPOC-20 scales and the parents’ satisfaction with the amount of service coordination (p = .000–.004). the researchers explain that the high scores accorded to respectful and supportive care and low scores on general information can be attributed to the families’ experience of relational help providing help to a larger extent.

Daldez et al (2018) conducted a study to explore the interest of the parent and family members in the participation in medical decision-making about the health of their children. In this study, the researchers recruited parents of hospitalized children ≤7 years old admitted to the inpatient service who were then interviewed regarding preferences for self-, other parent, and extended family involvement in decision-making.

Daldez et al (2018) compared the scores for the individual potential participant using the scale of 1 to 5 with 5 indicating that participants strongly agreed with the participation in the decision-making process. The authors used the x2 tests, the Wilcoxon rank tests and spearman correlation to assess the associations in the preferences in the making of decisions with regard to the aspects such as education, language, parental age and health as well as the level of clinical acuity Daldez et al (2018) enrolled 116 participants, with the parental media interest in decision making detailed in respect to the categorisations accorded by the researchers as; self (4.3; interquartile range [IQR]: 4–4.6); other parent (3.6; IQR: 2.7–4), and family (2.0; IQR: 1.7–2.7). Parents with better physical health (P< .001) and those in a relationship with the other parent (P < .001) were more likely to desire involvement of the other parent in medical decision-making. This was also true for those who faced higher acuity scenarios. Parents 35 years old (P .01) and those who were interviewed in Spanish (P= .03) were more likely to desire participation of extended family members. Daldez et al (2018) concluded that the parents of the children who were hospitalized wanted to participate in the decision making of the relevant medical aspects affecting their children though there were complexities in the desire for involvement of other family members. Curtis and Northcott (2017) conducted a study on the effects of the space in wards of hospitalised children on the application of family-centred care. This study was premised on the hospital building programs which mainly focused on the provision of single rooms for patients as opposed to shared rooms. Thus, the study researchers expressed concerns over the potential impacts of the spatial aspects if the paediatric wards on the application of family-centred care. The study was based on qualitative data analysis in an ethnographic sensitive manner and the method of data collection were structured in two phases In the first phase, which was named Phase 1, Curtis and Northcott (2017) conducted an observation within four wards of a specialist children's hospital. While the second phase, which they referred to as Phase 2, the researchers conducted a structured interview with 17 children, whose age ranged between 5 and 16 years as well as 60 parents of at the paediatric care unit. The researcher s also enrolled 60 nursing and support staff who took part both in the interviews and the focus group discussions. The data collected was analysed using a thematic model were the data was categorised into different themes. Following the data collection and analysis, the researchers identified two main themes which were used in the categorisation and presentation of data. The themes that were identified in this study were role expectations and family-nurse interactions. The researchers also explained that family-nurse interactions also comprised of family support needs, monitoring the wellbeing of the children and the resurvey- asset-interaction within spatial contests. Curtis and Northcott (2017) concluded that the configurations of the space within the hospital impacted significantly on the relationships and the interactions between children, parents and nurses with differences being evident between the single and shared rooms. This, the increased use of single rooms directly affects the manifestation of family centred care in practice. Makworo et al (2014) conducted a study to examine the application and effectiveness of family centred care by determining the status of the visitation of the hospitalised children in the medical health institutions in Kenya as well as the view of the parents and healthcare providers regarding the visitation of the hospitalised children by other children. This study was designed using the descriptive study that was carried out using mixed research methods, incorporating both quantitative and qualitative approaches research. The study was carried out at the paediatric wards at Kenyatta National Hospital (KNH) and Gertrudes Children’s Hospital (GCH), which are among the leading medical institutions in Kenya offering care to hospitalised children in Kenya. The researcher’s targeted the population which comprised of nurses, paediatric and parents of hospitalised children. Calculated using the Fischer’s formula, the sample size was composed of 161 for the parents. This was arrived at using multistage random sampling top select the parents who participated in the study. The data collection for the parents who participated in the in-depth interviews, the achievement of redundancy was the guideline for stopping using the interviews in data collections. Additionally, the researchers constructed a total of six focused groups with whom the discussion was conducted while the discussion was conducted separately for each category of the participants. Thus, the participants from one hospital were not mixed with those from the other hospital. Thus, the researchers constructed two focused groups for parents, two for nurses and two for the paediatric nurses. Data was collected using questionnaires, withy were both structured and unstructured were administered. These were also coupled with the in-depth interviews and focused group discussion guides.

Having collected and analysed the data, Makoworo et al (2014) identified that a total of 161 participants were involved in the phase one of the study, while 11 nurses who were not specialised in paediatric nursing as well as 13 paediatric nurse, additionally, 12 nurse managers, and 13 parents were involved in the in the second phase of the study. from the study, Makowor et al (2013) established that visitation of the hospitalised children by the family members especially for the children aged below 12 years is severely restricted in the public hospital. However, most of the healthcare providers and the parents acknowledged the importance and benefit of visitation of the hospitalised children by other children. The researchers presents that this visitation promotes the healing of the sick children, giving the psychological; satisfaction and relieves the anxiety of the hospitalised child as wee as the accompanying parent. The researchers identified that the risk of exposure of the visting children and family to the sick and hospitalised children is the main reason for the restriction of visiting the hospitalised children. However, Makworo et al (2014) concludes that both the healthcare providers and the hospitalised children’s parents appreciate the importance of the hospitalised child being visited by other children and thus creating the need to review the policies in healthcare to ensure that the hospitalised children are frequently visited and attended to by the parents and the family members since this will enhance family centred care.

The table below presents a synopsis of the above studies:

CHAPTER FIVE: DISCUSSION

The research findings, upon critical evaluation and analyzed brought about four main thematic concerns:

Hospital Facility Designs

The involvement of complicated family members for instance divorced parents, the extended family and guardians or family figures

The perception of the FCC model; by both parents and nurses

Limitation as to practical evidence and the lack of involvement of the children

5.1 Hospital Facility designs

The foregoing literature and researches by the distinguished scholars offer an eagle’s eye view into the general feeling in relation to FCC. The data speaks volumes over and above speaking for itself. The loudest of the opinion is with regard to the existing facilities, how they aid and how they would improve the application of FCC. It is apparent, from the analysis of data done by Curtis and Northcott (2017), that persons from both sides of the divide (parents as well as the professional health care providers) feel that the existing structure of hospital facilities may play and as a matter of fact affect the use of FCC in child care. The very lack of sufficient, ambient and proper hospital rooms may affect the involvement of family members in supporting child healthcare in hospitals. The outcome of their research is reasonable and expected. It cannot be that a room shared by more than two children would help in improving the use of FCC; in fact it is most certainly going to deteriorate the situation as it is expected that the patients will be affected psychologically. Indeed, Maben et al (2012) agrees that generally patients would feel connected more to those assisting them whenever they are in single rooms because they are able to freely engage with the medical staff as well as their family members. Moreover, from an objective point of view other patients would not be affected by the activities that come with FCC considering the nature of children as being restless and emotionally sensitive. Thus, parents feel more connected to their children in single rooms and alleviate the cognitive sensation that comes with attending to a patient in shared rooms. In summary, Maben et al (2012) connotes the statement from a patient that single rooms inspire the desire to have longer visitation hours from family members and one feels free to speak about the things that affect them more than they would in a shared room. The use of single rooms, however, hampers the work of the medical staff; especially where fathers are involved or where the patient and the family member present are not of the same gender and the medical problem is gender sensitive. Hence conclusively, the use of FCC would be far much more impactful if there was increased availability of single rooms in hospitals for inpatient care.

5.2 Involvement of not-so-close family members

The general sentiment from most research done is that involvement of FCC is hampered whenever separated or divorce parents are involved. Secondly, it becomes very difficult to build the welfare of the child whenever, whether due to cultural reasons or not, members of the extended family are involved. It appears that this scenario fails to achieve the primary objective of use of FCC which is to assist the medical staff in fast tracking the health outcome of a child. Kuo et al (2012) seems to conclude that the intended emotional effect of having family-centred care is not achieved if one parent refuses a divorced spouse entry to visit a patient child. The effect is the proverbial suffering of grass when two horses fight. The child is drawn in an unnecessary emotional battle and it may actually derail the healing and medical care process intended. Additionally, Puurveen et al (2018) opines that family dysfunction is a source of immense emotional trauma to a sick child and parents ought to get professional advice as to how to cope with the circumstances to achieve the best interests of the child. Moreover, as Makworo et al (2014) expresses, the African setting may not be the most conducive for FCC. That is to mean that the involvement of members of extended family in child health care may prove to be retrogressive in terms of the health of the child. This may be the case since too many people in the hospital rooms will hamper the operations of the medical staff in giving professional care to the child. If this cannot be easily managed, it may destroy the relationship between the medical staff and the family members, a relationship of which is critical in ensuring unified efforts towards improving the health of the child.

5.3 Stakeholders on the impact of FCC

From the onset, scholars’ research is divided into two main limbs; the opinion of the medical personnel versus the dogma of parents in relation to use of FCC over PCC. Over a wide range of issues, the congruence and divergence of opinion as to the practicability of FCC is in no uncertain terms. An important yet so divergent aspect is depicted in the research of Mallet et al (2019) where a large percentage of doctors appear not to agree to having parents around during ward rounds. Yet on the other hand, an overwhelming number of parents insist on being present during the morning rounds. Yet this finding may be criticized for the number of subject interviewees. 12 parents may not be necessarily a fair and correct representation of the general sentiment. Yet, still offer a clear distinction in opinion of stakeholders. However, all is not aloof; the FCC method appears to be the most favoured as it appeases the spirits of all stakeholders. Undeniably, researchers have found, as expounded in the foregoing chapters (such as Sarin and Maria, 2019), that parents and medical staff agree that FCC is the best method even when the hospital spaces do not allow continuous presence of outsiders or when it appears too cumbersome in shared hospital rooms. Hence we can safely conclude that FCC would suffice to be an important means of providing atraumatic healthcare hence minimizing psychological distress in sick children as Hockenberry and Wilson (2013) pg 14 put it. It appears that everybody is in favour of FCC for its very juicy benefits, yet we cannot dismiss that it comes with its own shortcomings.

5.4 The FCC model on atraumatic care and mutual benefit

So what makes FCC to be so attractive in comparison with the traditional forms of care? And does it come with its own strings attached? It is important to understand first, why FCC is so cherished in the modern children healthcare system.

5.4.1 Atraumatic care

Hockenberry and Wilson (2013) defined atraumatic care as the kind of inputs and inhibitions that tend to limit the emotional distress suffered by children undergoing medication. This has been the greatest hallmark of FCC as it is championed to have broken the ranks and built the general welfare of a child over and above healing the immediate health problem. Shields and Zhou (2011) connote that the 20th century saw the now infamous belief that presence of parents hampered proper delivery of health care services. However, in the mid-20th century British researchers started advocating for more involvement of the family in healthcare. Which has led, Shields and Zhou opine, to the now popular and correct belief that the more the involvement of the family in the health care of the child, the better the maintenance of the emotional wellbeing of a child during the traumatizing period of sickness. Thus, according to them it serves as the best means of achieving the best welfare of a child. I could not agree more, the continuous presence of parenting in a child’s life should not be arbitrarily curtailed simply because of an illness. The growth and development of a child does not cease upon contraction of a disease and such growth needs the institution of the family to stick with the child as in integral pillar to the welfare of a child.

The involvement of the family in the FCC model must not be passive in nature, but inclusive. The doctors must not treat parents as mere observers and cheerleaders but allow them to partake in the decision making process of the treatment of a child. That, Shields and Zhou (2011) argue, makes the difference between FCC and normal paediatric health care. The expected standard of FCC has been watered down in practice. It appears that what is on papers and explored literature has not been effectively implemented even though FCC has been in existence for close to a century. Shields as stated in Shields and Zhou (2011) conducted a Cochrane review of the practice of FCC in Britain since 1960s to 2004 and found that there is absolutely nothing to show of the implementation of FCC. Even in other European countries such as Italy, FCC is still a foreign practice in reality, as Festini (2014) connotes. However, Festini (2014) recognizes that FCC has had a major success, its biggest hallmark in achieving atraumatic care being the inclusion of compulsory physical presence of parents with a child in hospital. For him, the realization of full FCC in terms of atraumatic care is progressive.

Mutual Benefits

The foregoing research realizes that the use of FCC does not only benefit the emotional and psychological status of the child but also builds the relationship between the child and the family member as a co-paediatric. Clay et al (2016) report that FCC helps to incorporate the ideas of family members in the professional advice given by a paediatrician and this results to a stronger bond being created between the child and their family members. Indeed, the family members through the information passed to them in consultation with the medical staff, and vice versa, are able to learn more about child healthcare and this further helps in creating an environment of understanding between the child and the family member as to the state of affairs.

Moreover Girgin and Sivri (2015) relying on the research done by Cooper et al (2007), suggest that use of FCC helped ensure that family members acquired proper baby care skills especially where it involved neonatal care. Family members are able to understand the proper and healthy baby care skills through active presence during the period in hospital. This is crucial in a modern world where parents are deemed to be increasingly workaholic, hence denying most parents an opportunity to be part of the growth of their child, FCC offers a precious opportunity for the parents to acquire these skills and build emotional connections with the child that may remedy, albeit not completely, the lost time and bond at home.

This mutual benefit is not just created between the family members and the children only but also involves the nurses themselves even though FCC is built to move away from an authoritarian nursing mode. Girgin and Sivri (2015) relying on Yildiz (2008) study found that nurses become more educative and pass their knowledge to the parents from hospital admission to the to-do list upon discharge from the hospital. Hence it helps to alleviate the congestion of hospitals as well as educate family members on high standard but simple ways of taking care of children and infants. Hence the complains recorded by Coyne (2013), in Chapter 4, in relation to under-staffing of nurses and busy workloads as the source of poor implementation of FCC could easily be cured if those nurses were to apprentice the soft skills to the family members. This would easily ensure that the workload is reduced significantly. However, Coyne (2013) also argued that role training of parents by nurses could just give a quantitative result rather than qualitative result hence impeding the expected outcome of FCC. Such complains by nurses, in my opinion, appear to be sadistic and without any basis unless the situation is so dire that the ratio of nurses to patients does not accommodate quality apprenticeship.

Regardless, these strongholds of FCC are met with severe drawbacks which prove to be difficult to implement in most countries.

5.5 Implementation

The pace of modern medical reforms constantly portrays the need for change to be effected as to the model of care in hospitals, the service models in hospitals have gradually been changed from the patient centered models to the family centered models (Zhu et al, 2014).The FCC model is a model of health care that has been proposed in order to support the involvement of the family in the care of their children and significantly decrease distress levels experienced by all these parties through foundational factors such as decreasing conflicts and disagreements and improving the communication; especially between the health care service providers and the parents (Mikkelsen & Frederiksen, 2011).

Mayo- Bruinsma et al (2013), finds that service providers in Community Health Centers report high Family Centered care delivery than Family Health networks. The difference in this implementation can be attributed to the characteristics of the organizations. Some of these characteristics include the number of nurses in an institution, the access hours, number of clinical services, number of family physicians and the geographical location.

High provider- reported FCC was experienced where an organization was attributed to fewer family physicians, more clinical services, more nurses and more after access. These attributes can importantly be analyzed to develop the best practice models. In that regard, there is a relationship between the primary care model type and the number of nurse practitioners. The high scores in the practice of FCC associated with the high number of nurse might owe the prevalence on the establishment of nurses’ roles when in come to providing care. This can also be as a result of the scope of practice of the nurses which may involves some of processes that are present in the FCC instrument.

FCC reported by the patient is high across all studies. In the event that the physicians have too many patients to care for, their ability to provide FCC is compromised (Brookhart et al, 2010). The reports differences related to the alternative patient- centred care concept are significantly explained by the characteristics of the patients. These differences are also attributed to the the practice characteristics. There are, however, no characteristics that show that there is an effect of demographic characteristics on the FCC reported by the patient. Factors such as the age and sex of the patient would be relevant. FCC in practice is ultimately related to the satisfaction of the patient, older patients and female patients tend to be more content with the care model compared to the men and younger patients (Bamm et al, 2008).

According to Mayo- Bruinsma et al (2013), socioeconomic factors are also factors that directly relate to reporting FCC in care settings. Greater odds of reporting FCC came from patients with the lowest economic brackets. This suggests that the providers have a higher chance of building relationships with vulnerable patients. The FCC model is basically the best practice model in paediatrics (Makworo et al, 2016). This approach has its foundation on the emotional recognition of the needs of children in hospitals. Parents are often not directly involved with their children’s affairs in hospital; they are in most of these occasions not involved in the direct care of their children. In several of these instances, children are left unprepared for their diagnosed tests and procedures. The visitation hours, or times, are usually also controlled. The patient, in the FCC model, the patient is accorded the care and the focus is not given to the condition.

The FCC model focuses on the aspect of culture, goals, values, safety and patient satisfaction, and ultimately the family. These contexts are what are used to understand the patient, and not the condition. In most clinical settings, the atmosphere of the hospital and the contexts of care cause stress and discomfort to both the parent and the hospitalized children. The nursing staffs in these settings are often reluctant to interact with both the parents and the children In some settings, the mother is given very little thought in some of the major decisions of the child’s health care. The role of the mother is given very little thought in instances where the child is admitted to peadiatric care. Thus, practically, the main responsibility of the parent is usually to provide the medical practitioners with the information on the child’s condition and then preparing the child for treatment procedures as stated by the professional. Parents are not involved in the planning of the treatment plan and the implementation of care (Makworo et al, 2016). In spite of the model being emphasized even in training programs of the paediatric nurses, its practice is still limited. The strengths of the family and the individual remain highly rated as essential components in nursing practice.

The relationship or practice involving collaboration between professionals and parents receives less application due to reasons such as the nurse’s attitude towards what their responsibilities are and the number of nurses (Prasopkittikun et al, 2019). The environments of the hospital and its administration should be modified in a way which would support the implementation of this care model. Three basic themes arise in the implementation of FCC, psychosocial problems, limitations as to the structure and poor imbalance (Mirlashari et al, 2019). It implementation is usually shaped by the care provider, legal, cultural and application challenges. These influential factors should be addressed if an optimization of sustained and effective implementation is to be achieved. Changes should be effected if FCC is to be efficiently implemented. Changes in the organizational, operational and managerial structures are necessary to this effect. Within the neonatal and paediatric care units, the physicians and nurses are well positioned. They are figuratively the leaders and the basic facilitators of the implementation of FCC in their respective units.

The other thematic finding that could be discussed under implementation is the balancing act from the nurses’ perceptions. This finding, in a way, describes quality family- centered care. According to Coats et al (2018), 2 types of changes characterize this ‘balancing act’: physical transformations, especially those regarding the structures of the hospitals or the paediatric care units; and the paediatric care unit policies, especially those relating to visitation hours and the presence of the family members at the bedside during the whole process of care. There are various ways in which hospital settings have tried to support FCC. Some changes have included alterations of the policies and interactions in the hospitals. Some have included alterations in the physical environment. From the historical perspective, concerns for privacy, space and infection control only allowed parents to briefly visit their children who had been hospitalized. Research was however conducted and the results indicated that the presence of the parents at the bedsides of the children led to the children being more comfortable and less stressed. As a result, changes to allow for policies to accommodate longer visitation by families, including friendlier access were implemented to allow for the children to be more comfortable. The same also resulted in physical environmental changes which included transitions in hospital structures, such as the use of individual private wards instead of open floor plans.

It is also from a general perspective that it can be noted that nurses play a very critical role in the implementation of FCC in hospitals. Success implementation of the FCC model will always require the full cooperation of the nurses. In most instances, nurses act as the first points of contact for the families. Another reason for their critical role is the fact that they are consistently present at the bedside. These factors allows for them to importantly assess the coping abilities of the family members, their needs, concerns and the preferences as to the information they can convey. In doing so, nurses have a moral obligation to actually ensure that the needs of the family members are met in the process (Harrison, 2010). In the event, they also serve as educators basically because they facilitate communication between the family members and he physicians that handle their children; as a result of this facilitation, they are required to interpret medical information conveyed from the physicians to the family members and vice versa (Meert et al, 2013).

Increased bedtime presence of the families have huge benefits. The increased time, which is as a result of increased access, provides for forums in which nurses can be able to include the families in the care of the children, and also in the run, build better trust and relationships between them and the families. Through implementation, family members feel better involved in the care of the children. In Coats et al (2018), family members felt to have some sought of control and involvement in the care of their children in the intensive care units when the nurses involved them in some little tasks such as changing diapers, helping in various medical procedures or giving their children baths. These little tasks allowed the parents to assume parental roles even in hospital settings, which defines a crucial concept in the creation of the best relationship possible between the providers and the families. This concept also allowed the parents to trust the professional practitioners even more and even allowed a safe feeling to suffice even in the event that they have to leave the bedside. This increased access also allows for the creation of opportunities where the nurses can meet the needs of both the children and the parents.

Most parents would want to stay with their children in intensive care units. In the same context, they would always want to actively participate in the caring of their children during this time, while nimbly participating in the key decisions affecting them. Within that very umbrella, parents always want, also, to have their questions answered by the health care professionals, to have their concerns listened to and to know what the health care professionals expect from them in course of the care to their children (Boztepe, 2014). In the intensive care environment, and most other hospital environment, it is evident that the care model that best meets the expectations, concerns and the needs of parents is the FCC model of care. A child being hospitalized or admitted in intensive care units is always stressful both to the child and the parents. It is in this model that the whole family of the patients is included in the implementation, planning, evaluation and problem solving of the care that involves their children. It is also upon implementation of the model that the parents can actually have as much say as the health care professionals in regards to the health status of their children. The evaluation of the family’s and staff satisfaction during the process of FCC results in the demand for FCC model of care in hospitals globally. The FCC model meets the demands and needs of families with their children as patients and it is necessary to fully perfect and promote the practice.

Challenges

From various reviews, it is clear that implementing FCC is not easy in hospital settings. Various special units, such as the intensive care units and the paediatric units, still experience a lot of difficulties in implementing the FCC model into practice. Implementation of this model faces difficulties in practice that can be handled as either individual or institutional difficulties (Boztepe, 2014).

The main thematic concern that arises in this case is the view by nurses that the FCC model has great benefit for families but portrays new challenges for the nurses themselves (Coats et al, 2018). The transition to the FCC model to the nurses clearly had benefits for the families, however, the transition offered changes in the nursing practices and gave rise to new challenges, particularly those that regarded the safety of the patients and the staff and mentorship.

Paediatric care units, specifically the paediatric intensive care units prove to be very stressful environments on the patients and the families. This stressful environment places stressful demands on the families and the patients and may, in turn, have negative impacts on the psychosocial outcomes, both on a short term basis, or a long term basis. The complexity and seriousness of the condition of the child may also prove to be overwhelming to both the health care service providers and the parents (Aamir et al, 2014). The changes effected towards the implementation of this FCC model present their own challenges as well as benefits.

Policy changes as to access

Change that implement FCC in hospital settings allow for families to be able to visit their children in hospitals on a 24 hour basis. This increases the bedside presence of parents and provide for comfortability and positive outcomes in regards to the treatment of the child. This change allows for creation of opportunities in which parents receive real time information that involves their children. This increased bedtime presence also allows parents to provide hands on care alongside the health care providers.

In Coats et al (2018) the nurses reported that it is exhausting and distracting to actually have the families constantly at the bedside of their children. This applies especially in cases where provision of hands on care to a critically ill child is required and yet the family asks a lot of questions. The flow of thought and procedure is disrupted in the whole medical process where the parents constantly ask questions and want to know every little thing that the nurse does.

Some providers also bring forth the aspect of cultural shifts towards the FCC model of care. In some settings, families are greatly empowered to provide for more direct approaches to be followed by the nurses. The normal routine of the nurses might end up being changed in the short term care process and this essentially deviates from the nurses’ best forms of practice. This implementation shift embraces a more customer based approach in the process, which may result in the creation of conflicts, especially due to the basic mission and purpose of the nurses as to their approaches.

As a challenge during the implementation, nurses also feel a lot of pressure in performing when they are constantly being monitored and observed by the parents. This also makes the handing off difficult as the nurses have to explain in detail the medical situations of their patients to the next nurse at the point of change in shifts.

Physical environmental changes in the units

The transition in contention in this case refers to the restructuring of various paediatric units from single open rooms, multiple- bed rooms to private patient rooms where the nurses could work privately with respective families and the patient. Neither the single roomed nor shared spaces, however, creates the perfect environment for the delivery of the FCC model.

Different issues arose regarding the safety of the patient. This applies in scenarios where nurses may be overwhelmed by the number of patients hospitalized. In a shared environment, nurses would be able to hear and observe all the patients in the room, this also applies to the easy monitoring of multiple patients at the same time. This is not the case in a single and private room. The fact that both the patients and parents are isolated means that nurses monitoring a number of rooms could only see a single patient at a time, in some cases, these nurses may even have to move back and forth due to emergency alarms. In an open environment, nurses could easily grow as to their skills and practice. Mentorship was easily effective as the senior and well experienced nurses could easily see and monitor what their junior colleagues did as they were able to see them work. Feedback was therefore easily conveyed and changes as to the quality easily realized. In addition to the inability to effectively perform, nurses also worry about their own safety when left alone with family members. This often occurs in instances where the nurses have patients whose family members are hostile, upset or with inappropriate behaviors. Nurses often feel like they owe it to their own duties to watch over the patients even in such potential cases. These highlighted challenges need to be addressed following the implementation of the FCC model through the various manners. The lack of knowledge and skills on how to balance between the needs of the family and caring for the critically ill in the highly complex paediatric environments is the general challenge to implementation (Smith et al, 2015). Nurses constantly feel the need to prioritize complex and efficient care for the child over the family needs for involvement in the care of the child. This aspect raises challenges which classify clinicians’ attitudes towards the FCC model. The hospital administration should come up with policies that are meant to implement family centered care. The positives of the FCC model and the underlying concepts should also be shared with the family members so that the same may be promoted in cases where parents have their children hospitalized (Ramezani et al, 2014).

5.7 Study Limitations

5.7.1 Insufficient practical evidence

Most of the researchers have quite often pointed out that there is no practical evidence on FCC. In deed very few, if any, hospitals practice FCC to the expected standards n text. Hence there is difficulty in establishing the truth of the expected results. The studies done are therefore only provisional and the need to have conclusive researches is integral in developing an effective and fully realized FCC healthcare system

5.7.2 Children involvement in decision making

Perhaps from the analysis of literature it would have been wise to mention that there was no mention of research conducted on the patients themselves in Chapter Three. The scholars appear to have only focused on the opinions of the paediatrics and family members and none of it from children. Whereas the age of children may vary thus affecting their opinion, it is perhaps better if some research on the impact and the conduct of FCC is done on the child especially adolescent children. This is however met with limitation since most children are unable to make rational decisions or may be prone to lying or fear.

CHAPTER SIX: RECOMMENDATIONS AND CONCLUSION

It has been well noted that from a systematic point of view, parents would feel more connected and involved with the health care of their children if they are given more time and space with their children in hospitalized care. This may arise from the increased use of single rooms instead of shared rooms in hospital settings. The use of single rooms is connoted with the increase in desire to have longer hours of visitation from the family members, which in turn increases the outcome of the whole process (Maben et al, 2012).

Considerations should always be given to contextual factors that affect the family. This is because the existing systems of health care would always continue to put pressure on the family members in regards to role plays. These contextual factors include the employment status of the families, their health statuses and the geographic proximity (Puurveen et al, 2018). In addition to these factors, it is necessary to scrutinize how the involvement and experiences of the family is affected by things such as age, class, gender and race. Information in this field is significant in the enhancement of our understanding regarding the relationship between the patterns of involvement at the individual level and other macrostructural and relational factors.

Taking due regard on the limitation of the study, it would also be recommendable to pursue more practical results of the FCC model. Before further pursuing its development, a full recorded and evaluated trial of the model should be undertaken so that its impacts can be measured and ascertained. This is because despite being widely endorsed by various instructions and researchers, the FCC model is rarely applied in practice. This not only covers the theoretical aspect that already exists, but also provides a practical basis, which would be sturdy in the model’s development.

In medical scenarios, children have a number of rights according to Troil (2013). From legislative frameworks, it is clear that children have the right to growth and development in supportive and safe environments and surrounded by their families. They also have the right to be protected from violence, neglect, abuse or exploitation. Children ultimately have the right to be participating in decisions concerning them; this also includes their health. Additionally, in regards to health care, children have the right to enjoyment of the best possible health care and this should also involve the use of the best and most effective health care systems. In some instances, therefore, it is recommendable to also involve the children in the decision making. Involving the children is critical in the implementation of the FCC model as this aspect would primarily involve the specific wants and desires of the child. The need for involvement of the family members in the child’s hospital treatment and recovery is well founded. Notably, the development and growth of a child does not stop upon the contraction of an illness, this therefore should necessitate the institutions of health care to involve the family members. By involving the family members under this system of care, the emotional and physiological status of the child is built. This model not only builds this physiological and emotional status of the child in care, but also builds the relationship between the child and the family members involved. In addition to the improvement of the relationship between the family members and the children, the relationship between the parents and the professional health care providers is also improved. According to Girgin and Sivri (2015), nurses in their involvement with the family members, are even more educative and pass all the required knowledge on the whole process to the members of the patient’s family. This exchange of information between the parents and the nurses and other medical practitioners involved, is crucial in the facilitation of a better treatment and recovery outcome.

The inclusion of compulsory physical presence of the parents in hospitals is one of the biggest hallmarks in the achievement of atraumatic care (Festini, 2014). The full realization and implementation of the FCC model would therefore mark significant progression in atraumatic care. From a general perspective, therefore, the FCC is a better and much more progress model of system of care.

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