Family-Centered Care : An Evolutionary Concept Analysis

The lack of proper development of nursing concepts is one of the most important barriers to the continued development of nursing knowledge. Identifying and clarifying nursing concepts not only leads to descriptions and definitions, but also promotes the development of nursing theories.1,2 Discussing nursing concepts aids in their sensible use. Concept analysis not only provides meanings, but also explains how these meanings are expanded.2-4 In the last century, revolutionary changes have occurred in many political, social, and economic arenas of human life, and the health system is no exception. Its vision has changed from disease-centered to patientand family-centered healthcare. As an example, the year 1994 was introduced by the United Nations as the International Year of the Family. Scientific publications in the field of family-centered healthcare have led to increased public awareness.5


Introduction
The lack of proper development of nursing concepts is one of the most important barriers to the continued development of nursing knowledge.Identifying and clarifying nursing concepts not only leads to descriptions and definitions, but also promotes the development of nursing theories. 1,2Discussing nursing concepts aids in their sensible use.][4] In the last century, revolutionary changes have occurred in many political, social, and economic arenas of human life, and the health system is no exception.Its vision has changed from disease-centered to patient-and family-centered healthcare.As an example, the year 1994 was introduced by the United Nations as the International Year of the Family.Scientific publications in the field of family-centered healthcare have led to increased public awareness. 5story of the Concept of Family-Centered Care The year 1940 was the starting point for family-centered care.Rodgers' work some years later initiated patient-centered care in the field of psychology and introduced it as a continuous process.In this approach, therapists treat patients as a person with rights and importance and respect the rights and abilities of patients to guide their own treatment.
In 1959, Rodgers presented a diagram for the therapeutic relationship of family and society focused on the relationship and two-way effect of the treatment process, family changes, and participation and individual performance in social life. 6n 1960, Rodgers' idea was adopted in hospitals.Patientcentered care became family-centric, because the family plays an important role in the treatment of the child. 7In 1986, families were legally entitled to participate in the treatment of their children in a role equal to that of the professional healthcare staff. 8At present, the family is a part of a patient's healthcare team.Family participation in decision-making in the past 20 years has increased. 9Clarifying the importance of treating patients in the family has led to a change in vision from patient-centered care to the family-centered care for adults.The general understanding of the family as the most important educator, facilitator, and supporter has improved. 5,9n recent years, this concept has evolved and is now widely used.It is said to be applicable in all therapeutic areas, for patients of all ages, and in all environments.Some experts recommend this method as the best available practice.Given the widespread use of the concept and the evolving situation of healthcare systems, the present study aimed to clarify the concept of family-centered care. 10

Methods
Rodgers' evolutionary model has 8 steps.In this section, each of these steps and the work done in this study is briefly explained.In addition, some of the steps are merged.The steps are as follows: 1. Identifying the concept of interest 2. Identifying and selecting an appropriate sample and setting 3. Collecting data relevant to identifying attributes and the contextual basis 4. Analyzing the data 5. Identifying an exemplar of the concept 6. Identifying implications and hypotheses 1 Finding the Concept First, the concept is selected.The benefit of communication and application of the concept of family-based care for childcare has already been proven. 7In recent years, familycentered care has been accepted as a philosophy and foundation for treatment and care in all parts and conditions, but a literature review suggested that recent articles have only emphasized that this philosophy can also be used in adults. 11,12esearch has been done on various disciplines in this field. 13,14ealthcare workers have much difficulty with this concept in practice. 9,15Basic questions like how to provide essential information to the family; how to put aside specialized knowledge and just be a contributor; and when family members should be guided and when they should just listen remain unanswered.In addition, the use of the concept of family-centered care has not yet been clarified, not in the context of childcare, nor in other settings.There is insufficient evidence as to how family-centered care improves the outcome of the child and the family. 16Therefore, considering that one problem is in the application of this concept, the evolutionary method is a suitable method for concept analysis. 2ontrary to the philosophy of essentialism, the concept being analyzed is dynamical and varies over time. 1,17The evolutionary approach for the concept of family-based care is appropriate, because there is some evidence that has evolved over time and has changed with changes in the care environment. 3,18mple Selection, Resource Review and Data Analysis Rodgers mentioned the need to search extensively for resources.In this study, the keywords "family-centered care", "parental involvement", "family participation", and "care by family member" were used in searches on PubMed, Medline, Scopus, Science Direct, OVID, and SID databases.Public databases such as Google Scholar were also reviewed.Given the fact that the concept has a short, 40-year history, no attempt to limit the searches by time were made.
Articles retrieved from the searches were first generally examined in relation to the topic.Then, the articles that were determined to be relevant were assessed, and all data related to the properties of the concept, the antecedents, and the consequences were recorded on separate sheets.Most of the articles referred to Shelton's work in 1995, whose study seemed to provide a new area for family-centered care.Shelton provided a comprehensive framework for providing family-centered care to children.This framework has been used by parents of children with special educational needs and by others for children with chronic or critical illness. 19n this framework, community-based care is considered as a philosophy.When families and members of the treatment team are present, the normalized patterns of life are determined for the family.However, more research is needed to translate Shelton's framework into certain types of clinical practice.The researchers have emphasized that investigations into why it is difficult to implement family-centered care in acute conditions is needed.This framework is suitable for the care of a particular group of children with specific needs and is not transferable to other conditions.Given the different types of family-centered evolution in different countries and situations, it seems that Shelton's model does not apply to all working conditions.

Results
Family-Centered Care Dimensions After collecting articles, the focus turned to identifying the essence of the concept using its properties.The properties of a concept were not definitions in dictionary, but their actual application. 1At this stage, the main features of the concept were extracted from the available resources.The search in resources and articles identified particular dimensions shared by all family-centered care policies, as follows: 1. Families are experts about what helps them and what damages them; 2. Families are valuable partners for policymakers who help them; 3. Families are not dependent upon treatment, but they are contributing and empowering it; 4. Family-centered policies and practices promote family and community-based systems and provide bipartite support; and 5.The principles of democracy and gender equality are respected in these policies. 10ackean gave a rich overview of the key concepts of familycentered care that focused on: 1. Considering the family as the central element and the main source of strength and support; 2. Heeding the uniqueness and diversity of families and children; 3. Considering that parents are professional care providers; 4. Considering that family-based care is an enhancement of capabilities and not focusing on weaknesses; 5. Encouraging the partnership between the family and the treatment team; and 6.Facilitating families in supporting each other and creating a supportive network. 15n most studies, care has been identified as the main element of family-centered care. 10,15,20The definition of family-centered care was also extracted from the studies.Some have defined family-centered care as a holistic perspective, a philosophy that helps families care for their children, the basic principle of child care, parental care, parenting, and professional cooperation, and a chance for parents to care for their children under the supervision of professionals.Others have defined it as the contribution of the family to a care plan, a partnership that assists the family as a primary care provider.
Based on the available definitions, family-centered care has two basic dimensions.One is more general and defines a context which is collaborative with the family.In this perspective, the nurse is a contributor and facilitator of care.The other is more functional and less participatory.In this perspective, the nurse plays the role of a concierge; s/he is the dominant actor in the partnership and decides what care is provided by the parent and what care is provided by the nurse. 20This view was mostly focused on intensive care units, which provide specialized care.It seems that families are not able to carry out such advanced care, so their participation covered the simple care of patients and specialized work was performed by the nurse. 21Occasionally, the presence of nurses is likely to restrict parental care.Both models suggest ways to gain family control on conditions such as strong communication, family involvement, and participation in family-centered care. 20

Antecedents and Consequences
Rodgers stressed that a review of resources could lead to the clarification of the antecedents and consequences which could contribute to the clarification of the concept. 2 It seems that the presence of parents in the ward and their willingness to engage in childcare are the most important factors in accelerating family-centered care.In this study, based on the framework provided by Hutchfield, the antecedents were generally categorized as political-conceptual, economical, and motivational. 20nsequences of Family-Centered Care It seems that this concept is not well accepted in adult care, and multiple barriers to its implementation exist.Based on the resources, however, the results indicate that family-centered care benefits both the child and the family.
Improving family and patient satisfaction, 22 increasing self-efficacy, improving quality of life, 23,24 improving the information flow and interactions between families and treatment professionals, 25 helping intensive care patients to be aware of the care process, giving them relaxation and a sense of security, 26 improving communication between patient and family, achieving improved treatment outcomes, [27][28][29] acquiring a sense of re-control in family management, 30 reducing nursing job burnout, 31 creating a more effective relationship, increasing holistic nursing, 18,32 and reducing depression and fatigue among caregivers, 13,33,34 are the results extracted from studies on family-centered healthcare.
6][37] Thus, it is necessary to provide families with adequate support. 16del Case and Contrary Rodgers believed that the next stage of the process is identifying the model, borderline and contrary cases to help further identify the concept properties.Rodgers emphasized that pinpointing samples from personal experience is a good way to identify the essence of a concept.Parents who help provide physical or technical care represent a model case.Their involvement was voluntary, and efforts were made to promote and maintain the role of the family and its relationships.Moreover, parents' knowledge of their children was respected, and information was shared effectively. 20

Related Concepts
The available resources indicated that parental participation, participatory care, participation and relationship with parents are the concepts related to family-centered care.In the analysis carried out by Nethercott, a difference was detected between parental involvement and parental participation.In parental involvement, the nurse usually supervises parental activity; in participation, parents are more involved and nursing is less supervised. 38plication of the Concept and Further Research According to the review, family-centered care can be considered as a philosophy in providing care.It is applicable in all treatment areas and for all age groups.This concept has been taken from childcare and has been used in the care of adults.The review further showed that this concept is not welldefined in adults; further studies on this concept are needed.Some dimensions of the concept are not well defined.For example, it is not clear what cooperation and partnership is or how it works. 39,40It is also unclear which families can provide family-centered care or how much they can contribute to it.Some questions about this treatment approach remain.Is this approach similarly effective in all areas of treatment and for patients with different diagnoses or do differences exist?In what areas can family involvement be used?Can all the work or only special tasks be done by the family or family members?
In cases of acutely ill patients, the presence of family can intervene in or even prevent the continuation of treatment.For example, patients undergoing cardio-pulmonary resuscitation, the presence of family members may prevent the normal course of treatment.Such situations require more detailed assessment.Although this method is recommended as a suitable framework for the provision of healthcare, it is necessary to clarify its more obscure points for ease of use.

Conclusions
The results of the current study showed that family-centered care is an appropriate framework for the provision of health services.In recent years, this approach has been used in all environments, especially intensive care units, with promising results.Nevertheless, some points still require further studies for this approach to be effectively implemented.