Family-centered Care

Overtime, both the concept of family centred care (FCC) and the terms used to describe it have evolved. Over the last 20 years, there has been a shift from client-centredness to family-centredness. This began in the pediatric population and has since progressed to include the adult population. (Bamm & Rosenbaum, 2008). Several authors (Institute for Family Centered Care, n. d; MacKean, Thurston & Scott, 2004; Rosenbaum, et al. , 1998) have defined core concepts involved in family centred care.

Family-centred care (FCC) refers to an approach to healthcare that includes four key elements. First, people are treated with dignity and respect. Second, healthcare providers promote communication and information sharing with families in ways that are affirming and useful. Third, participation in experiences enhances families’ strengths, control, and independence. Fourth, ”collaboration among patients, families and providers occurs in policy and program development, professional education, and the delivery of care ” (Institute for Family Centered Care, 2008).

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FCC is an “an innovative approach to planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families” (Institute for Family Centred Care, 2008). The key elements of FCC “include that is affirming and useful, participation in care based on strengths, and collaboration among families and providers in care delivery, program development, and professional education” (Johnson, 2000, p. 14).

FCC developed from the assumption that the family is central and should be supported in promoting the health and well-being of the child (MacKean, Thurston ; Scott, 2004). Importance of Family-centred Care The World Health Organization (WHO) has identified that moving toward patient-centredness is important. The WHO highlights that “people centred health care is rooted in universally held values and principles which are enshrined in international law, such as human rights and dignity, non-discrimination, participation and empowerment, access and equity, and a partnership of equals” (WHO, 2007, p.

7). Further, the importance of involving the family is also noted by the WHO. In 2001, the Agency for Healthcare Research and Quality noted, “research has demonstrated that patients who are active participants in their care experience better outcomes than those who are not similarly engaged” (p. 15). Cooper et al. (2007) found that “the provision of family centred care enhanced the overall quality of NICU care resulting in less stressed, more informed and confident parents”. Challenges of family-centred care and Solutions

Rosenbaum et al. (1998) highlights an inherent threat in the move towards family centred care. That is, the authority shifts away from the practitioner as patients and families are becoming more informed and “professionals are being recognized as human and fallible… ” (p. 14). Further, critics have claimed that there is limited evidence to support the use of family-centered care practice (Dunst, Trivette & Hamby, 2007). A number of barrier to implementing family centred care have been considered in the literature.

Bamm and Rosenbaum (2008) discuss the barriers of political, conceptual, financial and attitudinal factors. In addition to these factors, Kelly (2007) identifies lack of ownership, lack of family involvement, power imbalance and culture of reluctance to challenge behavior as other potential barriers to the implementation of FCC. Glouberman and Zimmerman (2002) contend that many problems in health care are addressed as though they were a complicated problem when in fact they are a complex problem. They describe three types of systems: simple, complicated and complex.

Simple problems can be solved with a high degree of certainty once a “recipe” has been created that is effective. The application of certain steps in a specified order will bring about the same result. Glouberman and Zimmerman describe the differences between the three types of systems across the clusters of theory, causality, evidence and planning. Rowe and Hogarth (2005) also contend that the health care system is “suffering from the application of an outdated and inappropriate model” (p. 398).

A complex system cannot be properly managed employing a traditional machine-like model. The machinelike model assumes that change that is predictable, can be coordinated by senior management and that issues can be resolved through improved communication, standardization and performance management approaches. Paley (2001) describes the underlying assumptions in complex adaptive systems theory as “simple agents following simple rules that generate amazingly complex structures”. In this description agents may be individuals, units or departments.

Glouberman and Zimmerman (2002) also provide another assumption related to complex adaptive systems: the size of the initial change does not determine the size of future change or the outcomes. Holden (2005) agrees and writes that “non-linearity is a mathematical representation of the chaotic concept of, sensitive dependence upon initial conditions” (p. 465). Though the outcome may not be able to be predicted or controlled, that does not mean that we cannot understand the rules and interactions that are occurring. Though complex adaptive systems may be viewed as emergent and non-liner they can be assessed and modeled.

Paley (2007) contends that by better understanding the agents and the rules that they follow we can model the system and begin to understand how the interaction among the elements produce new structures and behavior. Rowe and Hogarth (2005) discuss the importance of “understanding the contradiction in planning for uncertainty and unpredictability” (p. 399). Rather than trying to control all of the inputs or mechanisms that may be involved, they highlight the importance of “creating the conditions in which [change] can occur” (p.

399). Some of the conditions that they highlight are the encouragement and development of new relationships, reflection, debate and challenge. They also highlight the importance of “participatory events” as a means for all staff to be involved in the process of determining the extent and nature of the change. These participatory events also led to the development of new generative relationships. These new relationships create new “emergent behaviors and work patterns” and often lead to new approaches or initiatives (p. 401).

Creating conditions for change have as a common thread in the ability to create a tension. Whether it is in the development of a new relationship, the debate regarding a is a mathematical representation of the chaotic concept of, sensitive dependence upon initial conditions” (p. 465). Though the outcome may not be able to be predicted or controlled, that does not mean that we cannot understand the rules and interactions that are occurring. Though complex adaptive systems may be viewed as emergent and non-liner they can be assessed and modeled.

Paley (2007) contends that by better understanding the agents and the rules that they follow we can model the system and begin to understand how the interaction among the elements produce new structures and behavior. Rowe and Hogarth (2005) discuss the importance of “understanding the contradiction in planning for uncertainty and unpredictability” (p. 399). Rather than trying to control all of the inputs or mechanisms that may be involved, they highlight the importance of “creating the conditions in which [change] can occur” (p.

399). Some of the conditions that they highlight are the encouragement and development of new relationships, reflection, debate and challenge. They also highlight the importance of “participatory events” as a means for all staff to be involved in the process of determining the extent and nature of the change. These participatory events also led to the development of new generative relationships. These new relationships create new “emergent behaviors and work patterns” and often lead to new approaches or initiatives (p. 401).

Creating conditions for change have as a common thread in the ability to create a tension. Whether it is in the development of a new relationship, the debate regarding a current practice or personal reflection, the outcome often is a tension between the old way of thinking or doing and possibility for change. This tension can then be utilized to move from homeostasis into a period of change. In considering the context of the Family Health Program, the application of CAS theory will allow for the development of recommendations that will match the level of complexity found in this organization.

As noted by Glouberman and Zimmerman (2002), the development of any strategy must first take into consideration the level of complexity of the issue at hand. Applying the Principle of Family-centred Care The purpose of this second part is to apply the family-centered care to a client/family in order to better understand how the principles of family-centred care were or were not applied to the situation. The subject is a 10 month old baby boy diagnosed with Right Fibular Hemimelia and wasoperated with the surgical procedure called Syme’s/Boyd Foot Amputation which caused him to be in severe pain most of the time.

So the nurse plays a crucial role by working with the client during the pre-operative, intraoperative and the initial post –operative phases and ensures proper pain management assessment and treatments. So nurses should learn more information about the assessment, the management and the impact of post-surgical pain on infants. Post-surgical pain is a complex response to tissue trauma during surgery that stimulates hypersensitivity of the central nervous system (Gehdoo, R. P. , 2004). Pain assessment is the most important and critical component of pain management.

This is where nurses faced daily dilemmas when trying to implement family-centered care principles in an already physically and emotionally charged patient and families due to the post-operative patient’s pain and the infant`s reactions (i. e. crying). Hence, understanding nursing strategies for active involvement and encouraging families to participate in caregiving is imperative ; however, it is equally important to recognize and accept family diversity in their role of being primary caregiver.

It must be acknowledge that in the vast majority of cases, family-centered care should be implemented in the constructed norms of pediatric surgery care. However, there are times in which this does not represent the best interests of the child, specifically when families lack cognitive and emotional capacity. Furthermore, a more family`s desire for involvement varies considerably, where not all parents have the same comfort level when participating in the care of their infant in pain.

In such cases, attempting to build a collaborative relationship requires diversity in the level of cooperation. Although nurses recognize the importance of parental and familial involvement in care duties, they report feeling cautious regarding the facilitation of this method of management. The knowledge a nurse must acquire to be competent with policy, equipment, and therapy in this area is extensive, thus making the role of the nurse more complex and demanding, especially when the transfer of care duties onto family members is associated with less expertly trained personnel.

The nurses though feeling responsible and accountable for the well-being of their neonatal patients and consequently feel obliged to monitor and supervise the activities performed by family members, to ensure the level of care meets the nurses` expectations. My understanding of the family-centered care method of health care delivery conceptualizes the importance of family functioning and family development, incorporating this mode of care into an acute care practice setting, such as the pediatric pain management, has resulted in many challenges.

My realizations is that nurturing this philosophy requires the participation of all professionals working cohesively in this environment; however, it is the nursing staff that has the most contact with post-operative pediatric patient’s pain families and ultimately play a pivotal role in the organizing care that supports this program in the everyday, twenty-four hour practice. Despite the expanding literature describing the positive benefits of this philosophy, there is a discrepancy between what is promoted as best-practice standard and the reality of clinical practice.

As the philosophy of family-centered care becomes integrated into pediatric pain management settings, continuing research is needed to inform how practice can be concurrently improved. The success of this approach ultimately depends upon the ability of health care providers to understand and support the practice behind the philosophy. References: Bamm, E. L. ; Rosenbaum, P. (2008). Family-centered theory: Origins, development, barriers, and supports to implementation in rehabilitation medicine. Archives of Physical Medical Rehabilitation. 89, 1618-1624. Cooper, L. G. , Gooding, J. S.

, Gallagher, J. , Sternesky, L. , Ledsky, R. ; Berns, S. D. (2007). Impact of family-centered care initiative on NICU care, staff and families. Journal of Perinatology. 27. S32-S37. Dunst, C. J. , Trivette, C. M. ; Hamby, D. W. (2007). Meta-analysis of family-centered helpgiving practices research. Mental Retardation and Developmental Disabilities Research Reviews. 13, 370-378. Gehdoo, R. P. (2004). Post Operative Pain Management in Pediatric Patients. Retrieved from: http://medind. nic. in/iad/t04/i5/iadt04i5p406. pdf Glouberman, S. ; Zimmerman, B. (2002). Complicated and complex systems: What

would successful reform of Medicare look like? Government of Canada. Discussion Paper No. 8, 2002. Holden, L. M. (2005). Complex adaptive systems: A concept analysis. Journal of Advanced Nursing. 52(6), 651 -657. Institute for Family Centered Care, (n. d. ) retrieved on July 13,2010 from http://www. familycenteredcare. org/index. html Kelly, M. T. (2007). Achieving family-centred care: Working on or working with stakeholders. Neonatal, Paediatric and Child Health Nursing. 10(3), 4-11. MacKean, G. L. , Thurston, W. E. ; Scott, C. M. (2005) Bridging the divide between

families and health professionals’ perspectives on family-centred care. Health Expectations. 8(1), 74-75 Paley, J. (2007). Complex adaptive systems and nursing. Nursing Inquiry. 14(3), 233-242. Rowe, A. & Hogarth, A. (2005). Use of complex adaptive systems metaphor to achieve professional and organizational change. Journal of Advanced Nursing. 51(4), 396- 405. World Health Organization. (2007). People-centred health care: A policy framework. Retrieved on July 13, 2010 from http://www. wpro. who. int/NR/rdonlyres/55CBA47E-9B93-4EFB-A64E- 21667D95D30E/0/PEOPLECENTREDHEATLHCAREPolicyFramework. pdf

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