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Nurses’ Attitudes Toward the Importance of Families in Nursing Care: A Multinational Comparative Study:

Nurses’ Attitudes Toward the Importance of Families in Nursing Care: A Multinational Comparative... The aim of this study was to examine nurses’ attitudes about the importance of family in nursing care from an international perspective. We used a cross-sectional design. Data were collected online using the Families’ Importance in Nursing Care— Nurses’ Attitudes (FINC-NA) questionnaire from a convenience sample of 740 registered nurses across health care sectors from Sweden, Ontario, Canada, and Hong Kong, China. Mean levels of attitudes were compared across countries using analysis of variance (ANOVA). Multiple regression was used to identify factors associated with nurses’ attitudes and to test for interactions by country. Factors associated with nurse attitudes included country, age, gender, and several practice areas. On average, nurses working in Hong Kong had less positive attitudes compared with Canada and Sweden. The effects of predictors on nurses’ attitudes did not vary by country. Knowledge of nurses’ attitudes could lead to the development of tailored interventions that facilitate nurse-family partnerships in care. Keywords nurse attitudes, family-focused care, survey, cross-sectional, cross-national comparisons et al., 2016). Family might be involved in various supporting Background roles, such as accompanying the patient to health care Family involvement in care processes is an important part of appointments and procedures, providing emotional support, providing patient- and family-focused care and ensuring care provision (Gusdal et al., 2017; Luttik et al., 2007), and optimal patient outcomes (Mackie et al., 2018; Park & surrogate (proxy) decision-making (Petriwskyj et al., 2014). Schumacher, 2014; Petriwskyj et al., 2014). Nurses play a Despite its importance, family involvement in care can be a central role in advocating and facilitating patient- and fam- ily-focused care practices (Mackie et al., 2018), including University of Toronto, Ontario, Canada social support for high family function and health (Shamali The Hong Kong Polytechnic University, Kowloon, Hong Kong et al., 2019). Family is a broad term that includes relatives, Karolinska Institutet, Stockholm, Sweden Karolinska University Hospital, Stockholm, Sweden friends, neighbors, or other individuals significant to the Stockholms Sjukhem, Sweden patient (Benzein, Johansson, Arestedt, & Saveman, 2008). University of Alberta, Edmonton, Canada From a Family Systems Nursing perspective, family is con- University of Copenhagen, Denmark ceptualized as the interaction, reciprocity, and relationships Herlev and Gentofte Hospital, Denmark between multiple systems (e.g., patient, family, nurse, health Corresponding Author: care system; Bell, 2009). Family is the unit of care (Bell, Lisa A. Cranley, Assistant Professor, Lawrence S. Bloomberg Faculty of 2009; Wright & Leahey, 1990) and family members’ involve- Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ment as care partners is key to providing quality patient care Ontario, Canada M5T 1P8. Email: lisa.cranley@utoronto.ca (Astedt-Kurki et al., 2001; Saveman et al., 2011; Voltelen 70 Journal of Family Nursing 28(1) challenging and complex process for health care providers families; Benzein, Johansson, Arestedt, & Saveman, 2008; and family (Petriwskyj et al., 2014). For example, lack of Gusdal et al., 2017; Hoplock et al., 2019). education about how to conduct therapeutic conversations Nurses’ attitudes toward involving families in care have with families and lack of time can act as barriers to nurses been studied in various health care settings and/or specialties actively involving families in care (Hoplock et al., 2019; (Benzein, Johansson, Arestedt, & Saveman, 2008), for Saveman, 2010). example, hospital/acute care (Blondal et al., 2014; Linnarsson A recent integrative review found that nurses’ attitudes et al., 2014); primary care (Oliveira et al., 2011); cardiovas- toward families may also help or hinder family’s involve- cular care (Gusdal et al., 2017; Luttik et al., 2017); psychiat- ment in care (Mackie et al., 2018). While positive attitudes ric/mental health care (Hsiao & Tsai, 2015; Sveinbjarnardottir toward families can lead to better communication, relation- et al., 2011); and pediatric care (Oh et al., 2018). Studies ships, and outcomes (Hoplock et al., 2019; Saveman, 2010), including more than one country (Luttik et al., 2017) or more less supportive attitudes may result in negative feelings than one health care setting in their sample have reported among family members (e.g., feeling excluded and less variation in nurses’ attitudes toward family importance in empowered to participate in care; Hoplock et al., 2019). care (Benzein, Johansson, Arestedt, & Saveman, 2008; From a reasoned action perspective, an attitude is defined as Gusdal et al., 2017; Hagedoorn et al., 2020; Hsiao & Tsai, an individual’s evaluation of an object, concept, or behavior 2015; Luttik et al., 2017; Østergaard et al., 2020). Luttik based on the degree of favorableness or unfavorableness et al. (2017) found that nurses living in Scandinavia had (Ajzen & Fishbein, 2000). Attitudes are determined by an more positive attitudes than nurses working in Belgium. individual’s beliefs and can guide one’s behavior (Ajzen & Studies have also reported that hospital nurses had less sup- Fishbein, 2000). Importantly, attitudes can also change portive attitudes than nurses in primary health care (Benzein, (Ajzen & Fishbein, 2000). As highlighted by Hoplock and Johansson, Arestedt, & Saveman, 2008; Gusdal et al., 2017; colleagues (2019), understanding nurses’ attitudes toward Hagedoorn et al., 2020; Østergaard et al., 2020) or home care family importance in nursing care is of critical importance as (Hagedoorn et al., 2020). However, in a Canadian study, attitudes can affect both nurses’ and family members’ behav- Hoplock et al. (2019) found no statistically significant differ- ior. Families are an important part of care planning and deliv- ences in attitudes between hospital nurses and home visiting ery (Saveman, 2010), and nurses’ attitudes toward the nurses. importance of family in the care process can contribute to the While there has been a growing body of literature on quality of the relationship that develops between nurses and nurses’ attitudes toward family importance in care, direct family (Alfaro Diaz et al., 2019). Linnarsson and colleagues comparisons and interpretation across studies are difficult (2014) reported that a positive attitude toward patients’ fami- due to differences in the inclusion criteria, sampling method, lies was associated with actively involving family members and demographic data collected. Such discrepancies among in care. these studies hinder a comprehensive understanding of Research examining nurses’ attitudes toward families’ nurses’ attitudes about family importance in nursing care. importance in nursing care has found that in general, nurses This study seeks to address this gap—this the first study to have positive attitudes (Benzein, Johansson, Arestedt, & our knowledge to examine nurses’ attitudes toward the Saveman, 2008; Blondal et al., 2014; Gusdal et al., 2017; importance of family in nursing care across all health care Hoplock et al., 2019; Hsiao & Tsai, 2015; Linnarsson et al., sectors from three countries. Few studies have examined 2014; Luttik et al., 2017; Østergaard et al., 2020; nurses’ attitudes toward families’ importance in care from an Sveinbjarnardottir et al., 2011). Recent literature provides international perspective (Luttik et al., 2017). There have some evidence that nurses’ attitudes vary based on individual been increasing calls for greater cross-national comparative characteristics. In general, nurses who expressed more posi- studies on nurse attitudes toward the importance of family in tive attitudes toward family importance in nursing care are care for a more comprehensive understanding of country older (Blondal et al., 2014; Østergaard et al., 2020); female similarities and differences (Gusdal et al., 2017; Hoplock (Linnarsson et al., 2014; Sveinbjarnardottir et al., 2011); et al., 2019; Luttik et al., 2017; Østergaard et al., 2020). have higher education levels (e.g., master’s or doctorate Knowledge of nurses’ attitudes of family importance in nurs- degree; Hagedoorn et al., 2020; Luttik et al., 2017; Østergaard ing care could lead to the development of education pro- et al., 2020); have more clinical experience (e.g., more than grams or interventions that facilitate collaboration and 7 years’ experience; Blondal et al., 2014; Hagedoorn et al., partnerships in care, implementation of policies, or organiza- 2020; Østergaard et al., 2020); have had a seriously ill family tional changes to involve families in care (Benzein, member in need of professional care (Benzein, Johansson, Johansson, Arestedt, & Saveman, 2008; Hoplock et al., Arestedt, & Saveman, 2008; Hsiao & Tsai, 2015; Linnarsson 2019; Sveinbjarnardottir et al., 2011; Yamazaki et al., 2017). et al., 2014; Østergaard et al., 2020; Sveinbjarnardottir et al., The aim of this study was to examine nurses’ attitudes 2011); and are employed in a workplace with a general about the importance of family in nursing care from an inter- approach to the care of families (i.e., the health care organi- national perspective. The specific study objectives were to zation has a general philosophy in place about the care of (1) describe and compare the level of nurse attitudes of the Cranley et al. 71 importance of family in nursing care across three countries; Data Collection (2a) identify predictors of nurse attitudes toward family Questionnaires were distributed online via a survey link pro- importance in nursing care; and (2b) determine whether pre- vided in the study invitation letter. Some advantages to using dictors vary by country. an online survey to collect data include ease of implementa- tion, reduced costs, respondents can answer the questions at Method their own convenience, and it has potential to increase response rates (Dillman et al., 2009). Data were collected in Design and Sample Sweden from October 2018 to March 2019, in Hong Kong, A cross-sectional study design was used to guide the study. China, from June 2019 to March 2020, and in Ontario, The Strengthening the Reporting of Observational Studies in Canada, from July 2019 to March 2020. We sent online Epidemiology (STROBE) checklist for cross-sectional stud- reminders to complete the survey to nursing associations and ies is appended (von Elm et al., 2007; Supplemental other professional nursing groups and through social media Appendix S1). Data were collected from a convenience sam- (depending on the country; Dillman et al., 2009). ple of registered nurses across health care sectors from Sweden, Ontario, Canada, and Hong Kong Special Measures Administrative Region of the People’s Republic of China (hereafter Hong Kong, China). The three countries were pur- Demographic characteristics. Demographic variables posefully selected based on our research team’s geographic included in the survey were nurses’ age, gender, workplace locations. Registered nurses currently working in any health setting, clinical specialty, education level, and have had a care setting (e.g., hospital, home and community care, long- seriously ill family member in need of professional care. As term care) were eligible to participate. Excluded were stu- educational requirements for nursing licensure vary across dent nurses, registered nurses not currently employed or the countries examined, we assessed the education level retired, nursing assistants, registered/licensed practical according to whether the nurse had obtained the first oblig- nurses, and nurse practitioners. atory professional training in nursing (bachelors or diploma An invitation to complete the online questionnaire was in Ontario, Canada, and Hong Kong, China, and bachelors sent to nursing associations or other professional nursing in Sweden) or had obtained a higher level of education interest groups and through social media (e.g., professional (e.g., postgraduate specialization certificate, masters, PhD). Facebook groups, Twitter, WhatsApp). The invitation letter In total, eight practice areas were derived based on clinical had information about the study purpose, voluntary partici- specialty and workplace setting and included the following: pation, confidentiality of the data, and implied consent (a) pediatric care (e.g., pediatric emergency, pediatric from those who complete and submit the survey. The invi- oncology); (b) maternal care (e.g., obstetrics, neonatal tation included a request for respondents to complete the care); (c) geriatric care (e.g., gerontology, long-term care); survey only once. Snowball sampling was also used as a (d) general medicine/surgery, herein called medical-surgi- recruitment strategy, by asking respondents to recruit addi- cal (e.g., oncology, cardiology, surgery, operating theater); tional nurses (Patton, 2014). The invitation letter included a (e) critical/acute care (e.g., intensive care, emergency request for respondents to send the invitation and link to the department); (f) mental health care (e.g., psychiatry); (g) questionnaire to other registered nurses they knew who any direct care provided outside of hospitals (e.g., public were currently working, through Facebook contacts or health, primary care, home care, community nursing); and other electronic means (Sadler et al., 2010). A target sample (h) nondirect care (e.g., care coordination, research, educa- size was estimated using rules of thumb for descriptive tion, administration). research based on population size because effect sizes for differences in the countries selected were unknown (Hill, Families’ Importance in Nursing Care—Nurses’ Attitudes (FINC- 1998). A sample of 385 per country was selected as returns NA) Questionnaire. The FINC-NA questionnaire was the out- in power for increased sample size begin to plateau at this come measure. FINC-NA is a 26-item questionnaire number (Hill, 1998). originally developed in Sweden by Benzein and colleagues that measures the attitudes of nurses toward the importance of involving families in nursing care (Benzein, Johansson, Ethical Considerations Arestedt, Berg, & Saveman, 2008). The FINC-NA question- Ethics approval was obtained from the University of Toronto, naire has four subscales: family as a resource in nursing care Ontario, Canada (Reference #37882), the Hong Kong (Fam-RNC) with 10 items, score range 10 to 50, assesses Polytechnic University’s Research Ethics Board (Reference positive attitudes toward family members and the value of #: HSEARS20190520001), and the Swedish Regional Board their presence in nursing care (e.g., “Family members should of Ethics (Reference 2018/1535-31). The survey was volun- be invited to actively take part in the patient’s nursing care”); tary, confidential, and anonymous. family as a conversational partner (Fam-CP) with eight 72 Journal of Family Nursing 28(1) items, score range 8 to 40, assesses attitudes toward the Scores for the FINC-NA were calculated for the overall importance of acknowledging the patient’s family members scale and each subscale. Means and standard deviations were and having dialogue with them (e.g., “I ask family members used to describe the level of attitudes in each country. Means to take part in discussions from the very first contact, when a were compared using ANOVA followed by pairwise com- patient comes into my care”); family as a burden (Fam-B) parisons. Post hoc analyses were conducted using the with four items, score range 4 to 20, assesses negative atti- Bonferroni method with adjusted p values. This method of tudes toward the presence family members and time to take adjusting for multiple comparisons was selected due to the care of families (e.g., “The presence of family members small number of tests required. There were very little item- makes me feel that they are checking up on me”); and family level missing data (maximum/per item n = 3). When item- as its own resource (Fam-OR) with four items, score range 4 level missing data occurred, individual-level mean imputation to 20, assesses attitudes toward family members as having was used. their own resources for coping (e.g., “I consider family mem- Multiple linear regression was used to identify predictors bers as co-operating partners”; Benzein, Johansson, Arest- of the overall scale and each subscale. Predictors selected a edt, Berg, & Saveman, 2008). priori included country, age, gender, education, have had a In this study, the revised version of the FINC-NA ques- seriously ill family member in need of professional care, and tionnaire was used (Saveman et al., 2011). The English ver- practice area. Reference groups were selected based on the sion of the survey was used in Ontario, Canada, and Hong largest sample size to maximize power of comparisons. Kong, China, and the Swedish version of the survey was Model diagnostics were undertaken prior to establishing a used in Sweden. The Swedish version of the FINC-NA has final model, including tests of multicollinearity and assess- been validated with Swedish nurses (Benzein, Johansson, ing linearity of the relationship between age and the out- Arestedt, Berg, & Saveman, 2008; Saveman et al., 2011). come. Model fit was assessed using the F statistic and the The English version has been used in Canada showing good adjusted R . To determine whether predictors varied accord- internal consistency of the scales (Hoplock et al., 2019). In a ing to country, interaction terms were created by multiplying recent review, the revised FINC-NA was found to be one of dummy variables representing the three countries by each of the best suited questionnaires to measure the importance of the predictors. A model containing main effects only was family involvement in clinical practice (Alfaro Diaz et al., compared with a second model containing the main effects 2019). We referred to “family” as individuals considered sig- and interaction terms. An omnibus test of interaction was nificant for the patient, such as family members, friends, or undertaken testing all interaction terms at once using F neighbors (Benzein, Johansson, Arestedt, & Saveman, 2008). change statistic for each outcome of interest by comparing In their refinement of the scale, Saveman and colleagues the first model with the second. Nonsignificant interactions (2011) revised the item responses to a 5-point Likert-type were removed from the final model. Complete case analysis scale (ranging from 1 = strongly disagree to 5 = strongly was used because there were less than 5% missing data in the agree), replacing the original 4-point Likert-type scale final multivariable models and no reason to assume the data (Benzein, Johansson, Arestedt, Berg, & Saveman, 2008). were not missing at random. The analysis was undertaken Item scores are summed to create a total score that range using SPSS (V 26). from 26 to 130. After reverse coding negatively worded items from the Fam-B subscale, higher scores indicated more Results positive attitudes (i.e., perceived family as less of a burden). The revised FINC-NA has good internal consistency with Sample Characteristics Cronbach’s alpha .92 for the total scale and greater than .70 After removing a total of 10 cases with significant missing for the subscales (range: .72–.86; Saveman et al., 2011). In data (only a few questions were answered) or that did not this study, the internal consistency using Cronbach’s alpha meet the inclusion criteria (e.g., retired, nurse practitioner), for the total scale ranged from .92 to .94 and the subscales our final sample included a total of 740 nurses, with 164 ranged from .70 to .89 (with the exception of the Fam-B sub- from Ontario, Canada, 214 from Hong Kong, China, and 362 scale for Hong Kong, China, α = .62). from Sweden. The mean age ranged from 37 years in Hong Kong, China (SD = 10.9), 41 years in Ontario, Canada (SD Data Analysis = 13.2), and 42 years in Sweden (SD = 9.9). While most nurses in each country were females, the proportion of males The demographic characteristics of the sample were varied significantly across countries, from a low of 3.7% in described using summary statistics, such as means and stan- Ontario, Canada, to a high of 20% in Hong Kong, China (p dard deviations for continuous variables (e.g., age) and fre- < .001). At least a third of the sample from each country had quency counts and percentages for nominal variables (e.g., more than the first professional training requirement in nurs- gender). Characteristics were compared across the three ing (e.g., postgraduate specialization certificate, masters, countries using analysis of variance (ANOVA) and chi- PhD) with the greatest number coming from Sweden (42%), square tests, as appropriate. Cranley et al. 73 Table 1. Demographics of the Participants. Ontario, Canada (n = 164) Hong Kong, China (n = 214) Sweden (n = 362) Demographic n (%) n (%) n (%) Statistic p value Age—M (SD) 40.9 (13.2) 36.6 (10.9) 42.1 (9.9) 17.25 <.001 Missing (n) 8 2 0 Gender Female 155 (96.3) 156 (80.0) 338 (93.4) 34.35 <.001 Male 6 (3.7) 39 (20.0) 24 (6.6) Missing (n) 3 19 0 Education First diploma or degree 107 (66.5) 129 (60.3) 207 (57.8) 3.50 .176 Postgraduate education 54 (33.5) 85 (39.7) 151 (42.2) Missing (n) 3 0 4 Practice area Primary care/home/ 26 (16.1) 26 (12.9) 37 (10.2) 51.09 <.001 community care Critical care 34 (21.1) 16 (8.0) 54 (14.9) Geriatric care 17 (10.6) 22 (10.9) 43 (11.9) Maternal care 18 (11.2) 11 (5.5) 12 (3.3) Medical-surgical 33 (20.5) 85 (42.3) 109 (30.1) Mental health care 9 (5.6) 17 (8.5) 25 (6.9) Pediatric care 10 (6.2) 11 (5.5) 33 (9.1) Nondirect care 14 (8.7) 13 (6.5) 49 (13.5) Missing (n) 3 13 0 Seriously ill family member Yes 137 (83.5) 122 (57.0) 300 (82.9) 56.00 <.001 No 27 (16.5) 92 (43.0) 62 (17.1) Missing (n) 0 0 0 a b c Chi-square test for categorical variables and F test for continuous variables. First obligatory nursing diploma or degree. Postgraduate education (e.g., masters, PhD, postgraduate specialization certificate). Have had a seriously ill family member in need of professional care. although the proportion did not vary significantly across .001), or Sweden (M = 104.6, SD = 14.8; p <.001); how- countries. More than 80% of nurses from Ontario, Canada, ever, no significant difference was found between Ontario, and Sweden have had a seriously ill family member in need Canada, and Sweden (p = .171). Analysis of the subscale of professional care; this proportion was significantly higher scores showed significant cross-country differences for than that found in Hong Kong, China (57%; p < .001). Fam-B and Fam-CP subscales. The mean score for Fam-B Although the largest proportion of nurses from each country was highest (perceived family as less of a burden) in Sweden worked in a hospital medical-surgical unit, some variation in (M = 16.3, SD = 3.3), followed by Ontario, Canada (M = the distribution of practice areas was observed. For example, 14.3, SD = 3.6), and lowest in Hong Kong, China (M = a higher proportion of nurses worked in maternal care or 11.2, SD = 2.6), with significant differences being found critical/acute care in Ontario, Canada, than in the other coun- between each pair of countries (p < .001). The mean score tries, whereas more nurses worked in medical-surgical units for Fam-CP was significantly lower in Hong Kong, China (M in Hong Kong, China, and Sweden than in Ontario, Canada = 31.3, SD = 4.3), than in Ontario, Canada (M = 32.8, SD (see Table 1). = 4.7; p = .01), or Sweden (M = 33.1, SD = 5.3; p <.001); however, no significant differences were found between Ontario, Canada, and Sweden (p = 1.00). Objective 1. Cross-Country Differences in Nurses’ Attitudes Toward Families’ Importance in Nursing Objective 2a. Factors Associated With Nurses’ Care Attitudes Toward Families’ Importance in Nursing The mean levels of the FINC-NA total scale and subscales Care for each country are found in Table 2. The total score was significantly lower in Hong Kong, China (M = 97.0, SD = Prior to establishing the factors associated with nurses’ atti- 11.7), than Ontario, Canada (M = 102.1, SD = 14.0; p = tudes, the presence of interactions by country was tested to 74 Journal of Family Nursing 28(1) Table 2. Comparison of the Mean Score of the Families’ Importance in Nursing Care—Nurses’ Attitudes (FINC-NA) Questionnaire Using ANOVA Analysis. Ontario, Canada Hong Kong, China (n = 164) (n = 214) Sweden (n = 362) Omnibus F test Subscale M (SD) M (SD) M (SD) statistic p value Family as a resource in nursing care 39.4 (6.1) 38.9 (5.3) 39.5 (5.5) 0.67 .510 Family as a conversational partner 32.8 (4.7)a 31.3 (4.3)ab 33.1 (5.3)b 9.82 <.001 Family as a burden 14.3 (3.6)ac 11.2 (2.6)ab 16.3 (3.3)bc 169.71 <.001 Family as its own resource 15.7 (2.6) 15.6 (2.4) 15.8 (3.1) 0.15 .865 Total 102.1 (14.9)a 97.0 (11.7)ab 104.6 (14.8)b 19.94 <.001 FINC-NA scale Note. Fam-B = reverse scores. Pairwise differences are indicated with matching letters (e.g., within each row, the number with an “a” is significantly different from the number with a matching “a” in the same row); for example, the Fam-B row shows the mean for this subscale in Canada (14.3) is significantly different from the Fam-B mean for Hong Kong (11.2). ANOVA = analysis of variance. Fam-B = family as a burden. Table 3. Predictors of Nurse Attitudes Toward Families’ Importance in Nursing Care—Total Score. 95% CI 95% CI Predictor B Lower bound Upper bound p value Ontario, Canada −2.187 −4.704 0.330 .088 Hong Kong, China −4.739 −7.223 −2.256 <.001 Education 1.981 −0.117 4.078 .064 Gender −3.607 −7.049 −0.165 .040 Age 0.321 0.228 0.413 <.001 Seriously ill family −1.010 −1.373 3.393 .405 Primary care 2.382 −0.877 5.642 .152 Critical care −4.011 −7.187 −0.834 .013 Geriatric care 4.605 1.272 7.938 .007 Maternal care 5.548 1.058 10.038 .016 Mental health care 3.376 −0.709 7.462 .105 Pediatric care 5.218 1.631 8.806 .004 Nondirect care 9.607 5.630 13.583 <.001 F value 13.13 (13, 690) <.001 Adjusted r .18 Note. N = 704. The total score of Families’ Importance in Nursing Care—Nurses’ Attitudes was used as the dependent variable. Nonsignificant interactions between country and predictors were removed. CI = confidence interval. a b c d Country reference group = Sweden. Education reference group = first obligatory nursing diploma or degree. Gender reference group = female. Have had a seriously ill family member in need of professional care. Primary care/home/community care; practice area reference group = medical-surgical unit. ensure correct model specification. There was no evidence 95% confidence interval [CI] = [−7.2, −2.3]; p ≤ .001). that incorporating interactions between each of the factors Males had significantly lower scores (B = −3.6, 95% CI = and country into the model improved fit for the total scale or [−7.0, −0.2]; p = .04), while age was associated with any of the subscales, judged by nonsignificant F change val- higher scores (B = 0.3, 95% CI = [0.2, 0.4]; p ≤ .001). ues, F change (22, 668) = 0.12–1.3, p = .14–.59. As a result, Finally, various practice areas were found to have higher the interactions were removed from the model and Objective or lower scores than the reference group of medical-surgi- 2a was evaluated using main effects only. cal area. Nurses working in critical care had lower total The final model of predictors of nurses’ attitudes toward scores (less positive attitudes) on average (B = −4.0, 95% family importance in nursing care is shown in Table 3. For CI = [−7.2, −0.8]; p = .01), whereas those working in the total scale score, significant predictors of nurse atti- geriatric care, maternal care, pediatrics, and areas involv- tudes included country, age, gender, and several practice ing nondirect care (e.g., care coordination, academia) had areas, including critical care, geriatric care, maternal care, significantly higher scores than nurses working in medi- pediatric care, and nondirect care. After accounting for all cal-surgical areas. Taken together, the predictors accounted other variables in the model, scores in Hong Kong, China, for 18% of the variation in the total score of FINC-NA were significantly lower than those in Sweden (B = −4.7, (Table 4). Cranley et al. 75 Table 4. Predictors of Nurse Attitudes Toward Families’ Importance in Nursing Care—Subscale Scores. Fam-RNC Fam-CP 95% CI 95% CI 95% CI lower 95% CI upper Predictor B Lower bound Upper bound p value B bound bound p value Ontario, Canada −0.015 −1.047 1.018 .978 −0.258 −1.149 0.632 .569 Hong Kong, China 0.377 −0.641 1.396 .467 −0.760 −1.639 0.118 .090 Education 0.616 −0.244 1.476 .160 0.631 −0.111 1.373 .095 Gender −1.317 −2.729 0.094 .067 −1.848 −3.065 −0.631 .003 Age 0.096 0.058 0.134 <.001 0.099 0.066 0.132 <.001 Seriously ill family −0.450 −0.527 1.428 .366 −0.351 −0.492 1.193 .414 Primary care 1.107 −0.229 2.444 .104 0.751 −0.402 1.904 .201 Critical care −1.629 −2.931 −0.326 .014 −1.075 −2.198 0.049 .061 Geriatric care 1.827 0.461 3.194 .009 1.817 0.638 2.996 .003 Maternal care 1.937 0.096 3.778 .039 1.817 0.229 3.406 .025 Mental health care 0.816 −0.860 2.491 .339 1.790 0.345 3.235 .015 Pediatric care 1.448 −0.023 2.919 .054 1.850 0.581 3.119 .004 Nondirect care 3.706 2.075 5.336 <.001 3.087 1.680 4.493 <.001 F value 6.82 (13, 690) <.001 10.06 (13, 690) <.001 Adjusted r .10 .14 Fam-B Fam-OR 95% CI 95% CI 95% CI upper Lower 95% CI upper Predictor B Lower bound bound p value B bound bound p value Ontario, Canada −1.840 −2.429 −1.251 <.001 −0.064 −0.586 0.457 .808 Hong Kong, China −4.630 −5.212 −4.049 <.001 0.275 −0.240 0.790 .294 Education 0.327 −0.164 0.818 .191 0.410 −0.025 0.844 .065 Gender 0.017 −0.789 0.822 .967 −0.459 −1.172 0.255 .207 Age 0.081 0.059 0.103 <.001 0.045 0.025 0.064 <.001 Seriously ill family −0.217 −0.341 0.775 .446 0 −0.495 0.457 1.000 Primary care −0.045 −0.808 0.718 .907 0.573 −0.103 1.249 .096 Critical care −0.873 −1.616 −0.129 .021 −0.434 −1.093 0.224 .196 Geriatric care 0.476 −0.304 1.256 .231 0.495 −0.195 1.186 .160 Maternal care 0.084 −0.211 1.891 .117 0.954 0.023 1.885 .045 Mental health care 0.255 −0.701 1.211 .601 0.524 0.023 1.885 .225 Pediatric care 1.020 0.180 1.859 .017 0.899 0.155 1.642 .018 Nondirect care 1.047 0.117 1.978 .027 1.772 0.948 2.597 <.001 F value 35.42 (13, 690) <.001 5.31 (13, 690) <.001 Adjusted r .39 .07 Note. N = 704. The total score of Families’ Importance in Nursing Care—Nurses’ Attitudes was used as the dependent variable. Nonsignificant interactions between country and predictors were removed. Fam-RNC = family as a resource in nursing care; Fam-CP = family as a conversational partner; Fam-B = family as a burden (reverse scores); Fam-OR = family as its own resource; CI = confidence interval. a b c d Country reference group = Sweden. Education reference group = first obligatory nursing diploma or degree. Gender reference group = female. Have had a seriously ill family member in need of professional care. Practice area reference group = medical-surgical unit. The models of the predictors of each of the subscales are considered, attitudes of family as more of a burden (lower found in Table 4. Of the four subscales, the predictors scores) were found in Hong Kong, China (B = −4.6, 95% CI accounted for most variation in the Fam-B subscale (39%) = [−5.2, −4.1], p < .001), and Ontario, Canada (B = −1.8, and least variation in the Fam-OR subscale (7%). Age was a 95% CI = [−2.4, −1.3], p < .001), compared with Sweden. significant predictor across all four subscales (outcomes; p Practice area was associated with each of the subscales, < .001), while country was only associated with scores on but the pattern of association varied. In comparison with the Fam-B subscale. Once all model variables were medical-surgical areas, nurses working in geriatric care were 76 Journal of Family Nursing 28(1) associated with higher scores in the Fam-RNC and Fam-CP may be cross-country differences in health care/workplace subscales. Working in maternal care was also related to policies regarding the presence of family and their involve- higher scores in the Fam-RNC and Fam-CP subscales, as ment in care. well as higher scores in the Fam-OR subscale. Working in Nurses working in Hong Kong, China, had significantly mental health care was associated with higher scores in the less positive attitudes toward the importance of family in Fam-CP subscale, while working in pediatrics was associ- nursing care than nurses working in Ontario, Canada, or ated with higher Fam-B scores (perceived family as less of a Sweden. We located only one other study that compared nurse burden), as well as higher scores in the Fam-CP and Fam-OR attitudes across several countries in their sample (Luttik et al., subscales. By contrast, working in critical care was associ- 2017). Luttik and colleagues (2017) found that nurses work- ated with lower scores (less positive attitudes) in the Fam-B ing in Scandinavian countries (i.e., Denmark, Norway, subscale and lower scores in the Fam-RNC subscale. Sweden) had more positive attitudes than nurses in Belgium. Working in nondirect care was consistently associated with As noted, there may be differences between countries in fam- more positive attitudes in all subscales. Finally, being male ily involvement in nursing care (Luttik et al., 2017). was associated with lower scores in the Fam-CP subscale (B While the proportion of male respondents was low over- = −1.8, 95% CI = [−3.1, −0.6], p = .003). Education level all, and particularly in Ontario, Canada, we found that gen- and having had a seriously ill family member in need of pro- der had an effect on the overall scores. This was largely fessional care were not significantly associated with any of derived from the Fam-CP subscale, where men were found the outcomes examined. to have less positive attitudes about family as a conversa- tional partner than women. Studies conducted in Sweden similarly found that men had less supportive attitudes for Objective 2b. Differences in Predictors by Country family as a conversational partner (Benzein, Johansson, The lack of evidence supporting the presence of statistical Arestedt, & Saveman, 2008; Linnarsson et al., 2014). interaction suggests that the effects of the predictors on Gender differences where men had less positive attitudes nurses’ attitudes were similar across the countries tested. than women have also been reported for the subscales Fam- RNC (Benzein, Johansson, Arestedt, & Saveman, 2008) and Fam-OR (Linnarsson et al., 2014; Sveinbjarnardottir Discussion et al., 2011). While it is not clear why these gender differ- To our knowledge, this is one of the first studies to examine ences exist, these findings may be due to cultural differ- nurses’ attitudes about the importance of family involvement ences between countries, or differences between male and in nursing care across all health care settings from an interna- female communication styles. In a review of studies exam- tional perspective. Our study objectives were to describe and ining gender differences in health care provider-patient compare the level of nurse attitudes of the importance of communication in medical encounters, Street (2002) noted family in nursing care across three countries; to identify pre- that research has suggested that men and women tend to dictors of nurse attitudes toward family importance in nurs- have different communication styles, which is associated ing care; and to determine whether predictors vary by with one’s socialization (e.g., gender roles, cultural norms, country. We found that country, age, gender, and practice values, beliefs, attitudes). For example, female health care area were significant predictors, and that all model predictors providers may be more interpersonally and relationally ori- accounted for 18% of the total variation in nurses’ overall ented such as building partnerships with patients than male attitudes (total scores) toward the importance of family in health care providers (Street, 2002). In a recent study nursing care. In the model of Fam-B, the predictors accounted exploring male nurses’ views of gender in the nurse-family for nearly 40% of the variation, a much higher percentage relationship in pediatric care, male nurses described how than that accounted for in the overall scale or the other sub- they exerted more control over the boundaries of relation- scales. Significant predictors of family as a burden included ships with families including limiting their emotional country, age, and practice areas. Examining the standardized involvement than their female colleagues (Arreciado regression coefficients, the effect of working in Hong Kong, Marañón et al., 2019). Street (2002) highlighted that one’s China, compared with Sweden was much larger relative to attitudes toward men and women may generate assump- the other model effects with family as a burden as the out- tions or gender-based beliefs about the capabilities and come; however, with the other subscales as outcomes, the needs of conversational partners. However, other studies relative difference in effects was much smaller. A similar pat- found no association between gender and nurses’ attitudes tern was also found for the effect of working in Ontario, toward the importance of family involvement in nursing Canada, compared with Sweden. By contrast, the effect size care (Alguire, 2013; Hoplock et al., 2019; Luttik et al., of age and practice area relative to the other model effects 2007). Ethnicity, age, and other factors including the was more consistent across all the models of the subscales. broader context of health care (e.g., political, cultural) may This suggests that the effect of country is more apparent in also influence communication patterns and interactions relation to attitudes of family as a burden, highlighting there (Street, 2002). Cranley et al. 77 Practice area was a significant predictor of nurses’ atti- of family in critical care and pediatric care have found that tudes. On average, nurses working in critical care had sig- health care professionals have positive attitudes toward fam- nificantly less positive attitudes about the importance of ily involvement in routine care, but they had less supportive family in nursing care overall compared with those working attitudes toward family presence during resuscitation efforts in medical-surgical areas. Those in practice areas of geriatric in critical care (Al Mutair et al., 2014) or complex, technical care (e.g., long-term care), maternal care, pediatrics, and tasks in the care of hospitalized children (Power & Franck, nondirect care had significantly more positive attitudes com- 2008). Studies examining health care professionals’ attitudes pared with the medical-surgical practice area. Practice areas toward family involvement in care have focused on specific were also associated with each of the subscales. For exam- care situations such as family presence during resuscitation ple, in comparison with nurses working in medical-surgical and other invasive procedures (Al Mutair et al., 2014). Liput units, nurses working in maternal care had more positive atti- and colleagues (2016) conducted a literature review that tudes about family as a resource in nursing care, family as its explored both health care professionals and family attitudes own resource, and family as a conversational partner. Nurses toward involvement in intensive care and found that they working in geriatric care, pediatrics, and mental health also share an attitude that a partnership is essential to provide reported more positive attitudes toward family as a conversa- optimal care. Strategies are needed such as education and tional partner. Nurses working in pediatrics and in nondirect training programs to facilitate family integration into the care roles perceived families as less of a burden. Previous model of care (Al Mutair et al., 2014; Liput et al., 2016). studies examining various specializations or work settings In this study, the education level was not a significant pre- have reported differences in nurse attitudes. For example, dictor of nurses’ attitudes toward family importance in nurs- intervention studies conducted in Iceland have reported vari- ing care. While this finding is consistent with previous ation in nurse attitudes between different psychiatric units research (Hoplock et al., 2019; Linnarsson et al., 2014), (Sveinbjarnardottir et al., 2011), and between outpatient and other studies reported an association between higher educa- day surgery departments and inpatient departments (Blondal tion level and more positive attitudes (Gusdal et al., 2017; et al., 2014). Hagedoorn et al., 2020; Luttik et al., 2017; Østergaard et al., Studies comparing hospital settings with home care or 2020; Sveinbjarnardottir et al., 2011). However, we assessed primary health care have been mixed. Researchers have education based on the first professional training require- found that nurses working in home care (Hagedoorn et al., ment in nursing (diploma or bachelor’s degree) and a higher 2020) or primary health care (Benzein, Johansson, Arestedt, level of postgraduate education (e.g., master’s, PhD) and the & Saveman, 2008; Gusdal et al., 2017; Hagedoorn et al., requirements for basic licensure varied across countries. 2020; Østergaard et al., 2020) reported more positive atti- Studies examining the impact of an education or training tudes than those working in hospitals. However, Hoplock intervention for nurses on the importance of involving fam- et al. (2019) reported no differences in nurses’ attitudes ily in care have shown that nurses perceived families as less among hospital and home care settings. In this study, there burdensome following training (Sveinbjarnardottir et al., were no significant differences in attitudes toward the impor- 2011; Yamazaki et al., 2017), and nurses’ understanding of tance of family in nursing care between nurses working in the importance of family in care was strengthened (Yamazaki primary care/home/community care compared with those et al., 2017). While Blondal et al. (2014) reported no differ- working in medical-surgical areas. ences in nurses’ attitudes before and after their educational Nurses working in nondirect care roles reported more intervention, they suggested tailoring interventions to prac- positive attitudes across all four subscales. Nurses in these tice areas. Including a control group in intervention studies roles may experience family involvement in care differently. may also be warranted. Interventions such as education or This finding is consistent with other studies that have training that are tailored to the practice area, and aim to reported more positive attitudes among researchers (Luttik develop skills and competencies in communicating and col- et al., 2017), educators, and managers (Alguire, 2013; Luttik laborating with families as active partners in the care pro- et al., 2017). As noted by Alguire (2013), nurses in roles such cess, are approaches that could support family-focused care as a manager or educator tend to spend less time at the bed- (Benzein, Johansson, Arestedt, & Saveman, 2008; Hoplock side, which limits their exposure to families and may explain et al., 2019; Hsiao & Tsai, 2015; Linnarsson et al., 2014; more positive attitudes. Luttik and colleagues (2017) further Luttik et al., 2017; Østergaard et al., 2020). For example, the noted that it can be difficult to implement a family-focused International Family Nursing Association (IFNA, 2015) out- approach in clinical practice, particularly when there are lined nurse competencies for generalist family nursing prac- time constraints or a lack of experience with involving fami- tice centered around five core competencies: lies in care (Benzein, Johansson, Arestedt, & Saveman, 2008). Actively involving family in care requires support (1) enhance and promote family health; (2) focus family nursing from the team including nurses, physicians, and other health practice on families’ strengths/ the support of family and care professionals (Liput et al., 2016). Studies examining individual growth/ the improvement of self-management abilities/ the facilitation of successful life transitions/ the health care professionals’ attitudes toward the involvement 78 Journal of Family Nursing 28(1) improvement and management of health/ the moblilzation of Research that examines nurse attitudes toward family family resources; (3) demonstrate leadership and systems involvement in care in long-term care settings could inform thinking skills to ensure the quality of nursing care with families targeted interventions in this setting. New and innovative in everyday practice and across every context; (4) commit to ways to involve families in care should be explored. self-reflective practice with families; and (5) practice using an evidence-based approach. (p. 3) Limitations Mentorship programs for novice nurses and manager sup- Our study provides a comprehensive understanding of nurse port for allocating dedicated time for nurses to establish attitudes toward the importance of family in nursing care trusting relationships with patients and family members from across all health care sectors in Hong Kong, China, could also contribute to meaningful family involvement in Ontario, Canada, and Sweden. However, there are limita- nursing care (Benzein, Johansson, Arestedt, & Saveman, tions to note. We used a convenience sample including snow- 2008; Gusdal et al., 2017; Hsiao & Tsai, 2015). Other modi- ball sampling which may affect results; for example, people fiable factors of the work environment such as ensuring that are connected by social media to people who tend to hold the best practice guidelines, policies (e.g., visitor policies), and same views. While accessing potential participants through workplace philosophies are in place that encourage family online social media can be a feasible and effective recruit- involvement in care are additional strategies that may sup- ment strategy (Whitaker et al., 2017), only nurses with access port family involvement in care (Hoplock et al., 2019). to online nursing professional groups and other online nurs- Providing client- and family-centered care is an entry- ing interest groups or social media groups had access to the level competency for registered nurses in the three countries survey. However, online data collection allows participants included in our sample (College of Nurses of Ontario, 2018; to complete the survey at their convenience, and data are The Nursing Council of Hong Kong, 2012; Swedish Nurses’ anonymous. While participants were invited to complete the Association, 2017). However, the content and amount of survey only one time, we cannot ensure that participants training in family-centered care varies across these nursing completed the survey only once. The use of representative programs, and family-centered care may not be well inte- samples in future research will be important to validate our grated into all practice areas (Hsiao & Tsai, 2015). Gaining model findings and demonstrate generalizability to wider an understanding about differences between countries in nursing populations. regard to attitudes toward family nursing has implications Sample sizes varied across countries, and in two of the for both practice (e.g., learning from other countries’ health three countries, the target sample size was not met despite care systems, policies) and education (e.g., understanding the use of best practices of internet recruitment and a long how nurses are trained to fulfill the core competencies out- recruitment period. Our data collection period and partici- lined by the IFNA, 2015). pant recruitment coincided with social unrest in Hong Kong, Future research should seek perspectives from various China, and it overlapped with the onset of COVID-19 in stakeholders such as registered/licensed practical nurses, spring 2020. As the statistical power of a comparison was nurse practitioners, other health care professionals, and fami- determined by the smallest sample size, cross-country com- lies for a more comprehensive understanding of attitudes and parisons with Ontario, Canada, had less power to detect a factors that may contribute to family involvement in nursing difference. In addition, as sample sizes to test interactions are care (Blondal et al., 2014; Hoplock et al., 2019). Research smaller than those for main effects, the power to detect inter- should further explore nurse attitudes toward family impor- actions was also limited due to smaller sample sizes in tance in care between direct clinical practice roles and nondi- Ontario, Canada, and Hong Kong, China, compared with rect nursing roles. Aside from the study conducted in Sweden. Future research should obtain samples across coun- Belgium and Scandinavian countries by Luttik and col- tries that are large and similar in size. Ideally, more countries leagues (2017), we located no other studies that examined would be included so that between-country variation would nurse attitudes of family importance in care from an interna- be better understood using multilevel models. In this study, tional perspective. Research should further explore cross- we could not determine the nature of the cross-country dif- country differences in nurse attitudes, as well as the role of ferences. For example, these could reflect different health culture in nurse attitudes toward family involvement in nurs- care policy environments or differences in cultural values. A ing care (Luttik et al., 2017). Knowing where cross-country recent qualitative study reported that factors such as the differences occur could inform targeted interventions and organizational environment, the patient’s condition, and the provides areas of research for future international compara- nurse’s attitudes and perceptions of family were factors that tive studies. Qualitative studies exploring cultural or cross- resulted in variation in practices for involving families in country differences may provide additional insights. care in intensive care units (Naef et al., 2021). However, To our knowledge, ours is the first study using the the manner in which nurses involve families in care is not FINC-NA to examine nurse attitudes toward family impor- well understood (Misto, 2018; Naef et al., 2021). Future tance in care that has included long-term care settings. studies making cross-country comparisons should explore Cranley et al. 79 the cultural, relational, and organizational context (e.g., and health care system-level factors that may contribute to organizational policies for family involvement in care, nurses’ attitudes toward the importance of family in nursing guidelines) with regard to nurses’ attitudes and the role of the care. family in nursing care (Naef et al., 2021). We only surveyed nurses in Ontario, Canada. While Acknowledgments Ontario is the most populous province in Canada, the sample We thank Ms. Lauren MacEachern (PhD student, Institute of Health size was low and it provides only a snapshot of one province Policy, Management and Evaluation, Dalla Lana School of Public within Canada. There were a low number of males included Health, University of Toronto) for conducting the literature review in the study, particularly in Ontario, Canada. This would for this article. We also wish to thank the nurses who participated in have reduced the power to detect gender effects, but also this study. interactions between gender and country. Future research should focus on obtaining a larger sample of male nurses to Declaration of Conflicting Interests better understand the effect of gender, and use a qualitative The author(s) declared no potential conflicts of interest with respect approach to explain gender differences in attitudes toward to the research, authorship, and/or publication of this article. the importance of family in nursing care. The internal consistency for the Fam-B subscale for Hong Funding Kong, China, was lower (α = .62) than that for the other two The author(s) received no financial support for the research, author- countries, suggesting that some items may be heterogeneous. ship, and/or publication of this article. Previous studies have reported a Cronbach’s alpha of <.70 for the Fam-B subscale (Benzein, Johansson, Arestedt, & Availability of Data and Materials Saveman, 2008; Blondal et al., 2014; Linnarsson et al., No data sets are available from this study as it is outlined in the 2014). As Blondal et al. (2014) noted, because this subscale protocol that only the research team will have access to the data. contains fewer items (four items), a Cronbach’s alpha of .60 or greater is acceptable (Nunnally & Bernstein, 1994). The ORCID iDs FINC-NA has not been previously tested in Hong Kong, Lisa A. Cranley https://orcid.org/0000-0002-3308-7558 China. Moreover, the FINC-NA has not, to our knowledge, Simon Ching Lam https://orcid.org/0000-0002-2982-9192 been tested for measurement invariance across languages; therefore, comparison of the mean scores needs to be done Anne-Marie Boström https://orcid.org/0000-0002-9421-3941 with some caution. Future international work using this instrument should be preceded by formal testing of measure- Supplemental Material ment invariance across languages to provide stronger evi- Supplemental material for this article is available online. dence of cross-national differences. In addition, we developed an education variable for which the requirements for basic References licensure varied across countries. Finally, categories of prac- Ajzen, I., & Fishbein, M. (2000). Attitudes and the attitude–behav- tice areas were developed in an effort to be consistent and ior relation: Reasoned and automatic processes. European these may not have corresponded exactly across the three Review of Social Psychology, 11(1), 1–33. https://doi. countries. However, including nurses working in a variety of org/10.1080/14792779943000116 practice areas across health care settings may increase the Alfaro Diaz, C., Esandi, N., Gutierrez-Aleman, T., & Canga- generalizability of our study findings. Armayor, A. 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Cranley, RN, PhD, is an assistant professor, Lawrence S. Advanced Nursing, 62(6), 622–641. https://doi.org/10.1111/ Bloomberg Faculty of Nursing, University of Toronto, Canada. Her j.1365-2648.2008.04643.x research interest is in models of care to support quality health care Sadler, G. R., Lee, H. C., Lim, R. S., & Fullerton, J. (2010). delivery in the long-term care sector. Her research focuses on Recruitment of hard-to-reach population subgroups via adap- unregulated health care providers’ scope of practice, older adult and tations of the snowball sampling strategy. Nursing & Health family engagement in care, and uptake of best practices in long- Sciences, 12(3), 369–374. https://doi.org/10.1111/j.1442- term care. She currently leads an intervention study to support older 2018.2010.00541.x adults and family caregivers’ engagement in care planning. Recent Saveman, B. I. (2010). Family nursing research for practice: The publications include “Understanding Professional Advice Networks Swedish perspective. Journal of Family Nursing, 16(1), 26–44. in Long-Term Care: An Outside-Inside View of Best Practice https://doi.org/10.1177/1074840709360314 Pathways for Diffusion” in Implementation Science (2019, with J. Saveman, B. I., Benzein, E., Engstrom, A. H., & Arestedt, K. M. Keefe et al.), “Strategies to Facilitate Shared Decision-Making (2011). Refinement and psychometric reevaluation of the in Long-Term Care” in International Journal of Older People instrument: Families’ Importance in Nursing Care—Nurses’ Nursing (2020, with S. Slaughter et al.), and “Expanding the Attitudes. Journal of Family Nursing, 17(3), 312–329. https:// Concept of End-of-Life Care in Long-Term Care: A Scoping doi.org/10.1177/1074840711415074 Review Exploring the Role of Health care Assistants” in Shamali, M., Konradsen, H., Stas, L., & Ostergaard, B. (2019). International Journal of Older People Nursing (2020, with D. Just, Dyadic effects of perceived social support on family health and H. O’Rourke, W. B. Berta, & C. Variath). family functioning in patients with heart failure and their near- est relatives: Using the actor-partner interdependence media- Simon Ching Lam, RN, PhD, FHKAN, is an assistant professor of tion model. PLOS ONE, 14(6), Article e0217970. https://doi. The School of Nursing and Deputy Director of Squina International org/10.1371/journal.pone.0217970 Centre for Infection Control, The Hong Kong Polytechnic Street, R. L. (2002). Gender differences in health care provider- University, Hong Kong SAR. His research focuses on the field of patient communication: Are they due to syle, stereotypes, or infection control, psychometric testing, and care of older adults. accommodation? Patient Education and Counseling, 48(3), Currently he is leading a project in establishing a testing certified 201–206. https://doi.org/10.1016/s0738-3991(02)00171-4 laboratory for assessing the quality of facemask and filtering mate- Sveinbjarnardottir, E. K., Svavarsdottir, E. K., & Saveman, B. I. rial as well as developing a new Chinese-specific N95 respirator, (2011). Nurses attitudes towards the importance of families in which both of these are important in the COVID-19 pandemic. psychiatric care following an educational and training inter- Recent publications include “Observational Study of Compliance vention program. Journal of Psychiatric and Mental Health With Infection Control Practices Among Healthcare Workers in Nursing, 18(10), 895–903. https://doi.org/10.1111/j.1365- Subsidized and Private Residential Care Homes” in BMC Infectious 2850.2011.01744.x Diseases (2021, with J. K. L. Au & L. K. P. Suen), “Global Swedish Nurses’ Association. (2017). Competence description Imperative of Suicidal Ideation in Ten Countries Amid the COVID- for a licensed nurse. swenurse.se/publikationer/kompetens- 19 Pandemic” in Frontiers in Psychiatry (2021, with T. Cheung beskrivning-for-legitimerad-sjuksköterska et al.), and “Face Mask Wearing Behaviors, Depressive Symptoms, Voltelen, B., Konradsen, H., & Østergaard, B. (2016). Family nurs- and Health Belief in Older People During the COVID-19 Pandemic” ing therapeutic conversations in heart failure outpatient clinics in Frontiers in Medicine (2021, with R. Y. C. Kwan, P. H. Lee, & in Denmark: Nurses’ experiences. Journal of Family Nursing, D. S. K. Cheung). 22(2), 172–198. https://doi.org/10.1177/1074840716643879 von Elm, E., Altman, D. G., Egger, M., Pocock, S. J., Gotzsche, Sarah Brennenstuhl, PhD, is an analyst and health researcher at P. C., & Vandenbroucke, J. P. (2007). STROBE initiative. the Lawrence S. Bloomberg Faculty of Nursing, University of The Strengthening the Reporting of Observational Studies in Toronto, Canada. She has advanced training in statistical methods Epidemiology (STROBE) statement: Guidelines for reporting and specializes in analysis of health inequalities and methods for observational studies. British Medical Journal, 355, 806–808. understanding the influence of distal factors on health status. Recent https://doi.org/10.1136/bmj.33335.541782.AD https://www. publications include “Researching the Health of Mothers of Young bmj.com/content/335/7624/806 Children Using Comparative Research Methods and Secondary Whitaker, C., Stevelink, S., & Fear, N. (2017). The use of Facebook Analysis of Population-Based Data” in SAGE Research Methods in recruiting participants for health research purposes: A sys- Cases (2020), “Development and Psychometric Evaluation of the tematic review. Journal of Medical Internet Research, 19(8), Preconception Health Knowledge Questionnaire” in American e290. https://doi.org/10.2196/jmir.7071 Journal of Health Promotion (2021, with Z. Cairncross et al.), and Wright, L. M., & Leahey, M. (1990). Trends in the nursing of fami- “A Comparison of Educational Events for Physicians and Nurses in lies. Journal of Advanced Nursing, 15(2), 148–154. https://doi. Australia Sponsored by Opioid Manufacturers” in PLOS ONE org/10.1111/j.1365-2648.1990.tb01795.x (2021, with Q. Grundy, S. Mazzarello, & E. Karanges). 82 Journal of Family Nursing 28(1) Zarina Nahar Kabir, PhD, is an associate professor of Public Health Angela Yee Man Leung, PhD, MHA, BN, RN, FHKAN at the Division of Nursing, Department of Neurobiology, Care (Gerontology), is a professor, Director of the Centre for Sciences and Society at Karolinska Institutet, Sweden. Her research Gerontological Nursing (CGN), and Deputy Director of WHO focuses on aging, family caregiving, mental health, and use of tech- Collaborating Centre for Community Health Services in the School nology in health care. She is currently leading an intervention study of Nursing of Hong Kong Polytechnic University. She is also the using mHealth to support family caregivers of persons with demen- Theme Leader of research theme “Aging and Health” in the School tia. She is also a coinvestigator of a rapid response survey on COVID- of Nursing. She is an active researcher in health literacy and demen- 19 in Bangladesh. Recent publications include “In Conversation tia caregiving, with a wide range of publications in international With a Frontline Worker in a Care Home in Sweden During the journals. Recent publications include “Care of Family Caregivers COVID-19 Pandemic” in Journal of Cross-Cultural Gerontology of Persons With Dementia (CaFCa) Through a Tailor-Made Mobile (2020, with A. M. Boström & H. Konradsen) and “Care of Family App: A Study Protocol of a Complex Intervention Study” in BMC Caregivers of Persons With Dementia (CaFCa) Through a Tailor- Geriatrics (2020, with Z. N. Kabir et al.), “A Mobile App for Made Mobile App: A Study Protocol of a Complex Intervention Identifying Individuals With Undiagnosed Diabetes and Prediabetes Study” in BMC Geriatrics (2020, with A. Y. M. Leung et al.). and Changing Behavior: 2-Year Prospective Study” in Journal of Medical Internet Research (2018, with X. Y. Xu et al.), and Anne-Marie Boström, RN, PhD, is an associate professor in “Behavioural Activation for Family Dementia Caregivers: A Nursing at Karolinska Institutet and Director for Nursing Systematic Review and Meta-Analysis” in Geriatric Nursing Development at Karolinska University Hospital, Theme Aging and (2020, with X. Y. Xu & R. Y. C. Kwan). Inflammation, Huddinge in Sweden. Her research focuses on health and well-being for older persons with or without dementia, and she Hanne Konradsen, RN, PhD, is a professor in clinical nursing at is also conducting research on the dissemination and implementa- Herlev and Gentofte University Hospital and University of tion of research findings and evidence in the care of older adults. Copenhagen in Denmark and an associate professor at Karolinska She is Principal Investigator for the Older Person’s Exercise and Institute in Sweden. Her research is focused on the interplay Nutrition (OPEN) study and is participating in an intervention study between innovation and nursing. Currently she is participating in a to evaluate the effect of support using a mobile application to a fam- study on the effect on family support mediated by a mobile applica- ily member caring for a person with dementia at home. Recent pub- tion, the use of virtual reality in caring for children, and how best to lications include “Response and Adherence of Nursing Home use hospital design to optimize the effect of nursing. Recent publi- Residents to a Nutrition/Exercise Intervention” in Journal of the cations include “Providing Dementia Care Using Technological American Medical Directors Association (2021, with E. Karlsson Solutions: An Exploration of Caregivers’ and Professionals’ et al.), “A Learning Process Towards Person-Centred Care: A Experiences of Using Technology in Everyday Life With Dementia Second Year Follow-Up of Guideline Implementation” in Care” in Journal of Clinical Nursing (2020, with S. Kristiansen, M. International Journal of Older People Nursing (2021, with K. Beck, & Z. N. Kabir), “The COVID-19 Pandemic: A Family Affair Kindblom, D. Edvardsson, & S. Vikström), and “Being Treated [Guest Editorial]” in Journal of Family Nursing (2020, with M. L. With Respect and Dignity? Perceptions of Home Care Service Luttik et al.), and “Factors Associated With Family Functioning in Among Persons With Dementia” in Journal of the American Patients With Heart Failure and Their Family Members: An Medical Directors Association (2021, with L. Marmstål Hammar, International Cross-Sectional Study” in Journal of Advanced M. Alam, M. Olsen, & A. Swall). Nursing (2021, with M. Shamali et al.) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Family Nursing SAGE

Nurses’ Attitudes Toward the Importance of Families in Nursing Care: A Multinational Comparative Study:

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Abstract

The aim of this study was to examine nurses’ attitudes about the importance of family in nursing care from an international perspective. We used a cross-sectional design. Data were collected online using the Families’ Importance in Nursing Care— Nurses’ Attitudes (FINC-NA) questionnaire from a convenience sample of 740 registered nurses across health care sectors from Sweden, Ontario, Canada, and Hong Kong, China. Mean levels of attitudes were compared across countries using analysis of variance (ANOVA). Multiple regression was used to identify factors associated with nurses’ attitudes and to test for interactions by country. Factors associated with nurse attitudes included country, age, gender, and several practice areas. On average, nurses working in Hong Kong had less positive attitudes compared with Canada and Sweden. The effects of predictors on nurses’ attitudes did not vary by country. Knowledge of nurses’ attitudes could lead to the development of tailored interventions that facilitate nurse-family partnerships in care. Keywords nurse attitudes, family-focused care, survey, cross-sectional, cross-national comparisons et al., 2016). Family might be involved in various supporting Background roles, such as accompanying the patient to health care Family involvement in care processes is an important part of appointments and procedures, providing emotional support, providing patient- and family-focused care and ensuring care provision (Gusdal et al., 2017; Luttik et al., 2007), and optimal patient outcomes (Mackie et al., 2018; Park & surrogate (proxy) decision-making (Petriwskyj et al., 2014). Schumacher, 2014; Petriwskyj et al., 2014). Nurses play a Despite its importance, family involvement in care can be a central role in advocating and facilitating patient- and fam- ily-focused care practices (Mackie et al., 2018), including University of Toronto, Ontario, Canada social support for high family function and health (Shamali The Hong Kong Polytechnic University, Kowloon, Hong Kong et al., 2019). Family is a broad term that includes relatives, Karolinska Institutet, Stockholm, Sweden Karolinska University Hospital, Stockholm, Sweden friends, neighbors, or other individuals significant to the Stockholms Sjukhem, Sweden patient (Benzein, Johansson, Arestedt, & Saveman, 2008). University of Alberta, Edmonton, Canada From a Family Systems Nursing perspective, family is con- University of Copenhagen, Denmark ceptualized as the interaction, reciprocity, and relationships Herlev and Gentofte Hospital, Denmark between multiple systems (e.g., patient, family, nurse, health Corresponding Author: care system; Bell, 2009). Family is the unit of care (Bell, Lisa A. Cranley, Assistant Professor, Lawrence S. Bloomberg Faculty of 2009; Wright & Leahey, 1990) and family members’ involve- Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ment as care partners is key to providing quality patient care Ontario, Canada M5T 1P8. Email: lisa.cranley@utoronto.ca (Astedt-Kurki et al., 2001; Saveman et al., 2011; Voltelen 70 Journal of Family Nursing 28(1) challenging and complex process for health care providers families; Benzein, Johansson, Arestedt, & Saveman, 2008; and family (Petriwskyj et al., 2014). For example, lack of Gusdal et al., 2017; Hoplock et al., 2019). education about how to conduct therapeutic conversations Nurses’ attitudes toward involving families in care have with families and lack of time can act as barriers to nurses been studied in various health care settings and/or specialties actively involving families in care (Hoplock et al., 2019; (Benzein, Johansson, Arestedt, & Saveman, 2008), for Saveman, 2010). example, hospital/acute care (Blondal et al., 2014; Linnarsson A recent integrative review found that nurses’ attitudes et al., 2014); primary care (Oliveira et al., 2011); cardiovas- toward families may also help or hinder family’s involve- cular care (Gusdal et al., 2017; Luttik et al., 2017); psychiat- ment in care (Mackie et al., 2018). While positive attitudes ric/mental health care (Hsiao & Tsai, 2015; Sveinbjarnardottir toward families can lead to better communication, relation- et al., 2011); and pediatric care (Oh et al., 2018). Studies ships, and outcomes (Hoplock et al., 2019; Saveman, 2010), including more than one country (Luttik et al., 2017) or more less supportive attitudes may result in negative feelings than one health care setting in their sample have reported among family members (e.g., feeling excluded and less variation in nurses’ attitudes toward family importance in empowered to participate in care; Hoplock et al., 2019). care (Benzein, Johansson, Arestedt, & Saveman, 2008; From a reasoned action perspective, an attitude is defined as Gusdal et al., 2017; Hagedoorn et al., 2020; Hsiao & Tsai, an individual’s evaluation of an object, concept, or behavior 2015; Luttik et al., 2017; Østergaard et al., 2020). Luttik based on the degree of favorableness or unfavorableness et al. (2017) found that nurses living in Scandinavia had (Ajzen & Fishbein, 2000). Attitudes are determined by an more positive attitudes than nurses working in Belgium. individual’s beliefs and can guide one’s behavior (Ajzen & Studies have also reported that hospital nurses had less sup- Fishbein, 2000). Importantly, attitudes can also change portive attitudes than nurses in primary health care (Benzein, (Ajzen & Fishbein, 2000). As highlighted by Hoplock and Johansson, Arestedt, & Saveman, 2008; Gusdal et al., 2017; colleagues (2019), understanding nurses’ attitudes toward Hagedoorn et al., 2020; Østergaard et al., 2020) or home care family importance in nursing care is of critical importance as (Hagedoorn et al., 2020). However, in a Canadian study, attitudes can affect both nurses’ and family members’ behav- Hoplock et al. (2019) found no statistically significant differ- ior. Families are an important part of care planning and deliv- ences in attitudes between hospital nurses and home visiting ery (Saveman, 2010), and nurses’ attitudes toward the nurses. importance of family in the care process can contribute to the While there has been a growing body of literature on quality of the relationship that develops between nurses and nurses’ attitudes toward family importance in care, direct family (Alfaro Diaz et al., 2019). Linnarsson and colleagues comparisons and interpretation across studies are difficult (2014) reported that a positive attitude toward patients’ fami- due to differences in the inclusion criteria, sampling method, lies was associated with actively involving family members and demographic data collected. Such discrepancies among in care. these studies hinder a comprehensive understanding of Research examining nurses’ attitudes toward families’ nurses’ attitudes about family importance in nursing care. importance in nursing care has found that in general, nurses This study seeks to address this gap—this the first study to have positive attitudes (Benzein, Johansson, Arestedt, & our knowledge to examine nurses’ attitudes toward the Saveman, 2008; Blondal et al., 2014; Gusdal et al., 2017; importance of family in nursing care across all health care Hoplock et al., 2019; Hsiao & Tsai, 2015; Linnarsson et al., sectors from three countries. Few studies have examined 2014; Luttik et al., 2017; Østergaard et al., 2020; nurses’ attitudes toward families’ importance in care from an Sveinbjarnardottir et al., 2011). Recent literature provides international perspective (Luttik et al., 2017). There have some evidence that nurses’ attitudes vary based on individual been increasing calls for greater cross-national comparative characteristics. In general, nurses who expressed more posi- studies on nurse attitudes toward the importance of family in tive attitudes toward family importance in nursing care are care for a more comprehensive understanding of country older (Blondal et al., 2014; Østergaard et al., 2020); female similarities and differences (Gusdal et al., 2017; Hoplock (Linnarsson et al., 2014; Sveinbjarnardottir et al., 2011); et al., 2019; Luttik et al., 2017; Østergaard et al., 2020). have higher education levels (e.g., master’s or doctorate Knowledge of nurses’ attitudes of family importance in nurs- degree; Hagedoorn et al., 2020; Luttik et al., 2017; Østergaard ing care could lead to the development of education pro- et al., 2020); have more clinical experience (e.g., more than grams or interventions that facilitate collaboration and 7 years’ experience; Blondal et al., 2014; Hagedoorn et al., partnerships in care, implementation of policies, or organiza- 2020; Østergaard et al., 2020); have had a seriously ill family tional changes to involve families in care (Benzein, member in need of professional care (Benzein, Johansson, Johansson, Arestedt, & Saveman, 2008; Hoplock et al., Arestedt, & Saveman, 2008; Hsiao & Tsai, 2015; Linnarsson 2019; Sveinbjarnardottir et al., 2011; Yamazaki et al., 2017). et al., 2014; Østergaard et al., 2020; Sveinbjarnardottir et al., The aim of this study was to examine nurses’ attitudes 2011); and are employed in a workplace with a general about the importance of family in nursing care from an inter- approach to the care of families (i.e., the health care organi- national perspective. The specific study objectives were to zation has a general philosophy in place about the care of (1) describe and compare the level of nurse attitudes of the Cranley et al. 71 importance of family in nursing care across three countries; Data Collection (2a) identify predictors of nurse attitudes toward family Questionnaires were distributed online via a survey link pro- importance in nursing care; and (2b) determine whether pre- vided in the study invitation letter. Some advantages to using dictors vary by country. an online survey to collect data include ease of implementa- tion, reduced costs, respondents can answer the questions at Method their own convenience, and it has potential to increase response rates (Dillman et al., 2009). Data were collected in Design and Sample Sweden from October 2018 to March 2019, in Hong Kong, A cross-sectional study design was used to guide the study. China, from June 2019 to March 2020, and in Ontario, The Strengthening the Reporting of Observational Studies in Canada, from July 2019 to March 2020. We sent online Epidemiology (STROBE) checklist for cross-sectional stud- reminders to complete the survey to nursing associations and ies is appended (von Elm et al., 2007; Supplemental other professional nursing groups and through social media Appendix S1). Data were collected from a convenience sam- (depending on the country; Dillman et al., 2009). ple of registered nurses across health care sectors from Sweden, Ontario, Canada, and Hong Kong Special Measures Administrative Region of the People’s Republic of China (hereafter Hong Kong, China). The three countries were pur- Demographic characteristics. Demographic variables posefully selected based on our research team’s geographic included in the survey were nurses’ age, gender, workplace locations. Registered nurses currently working in any health setting, clinical specialty, education level, and have had a care setting (e.g., hospital, home and community care, long- seriously ill family member in need of professional care. As term care) were eligible to participate. Excluded were stu- educational requirements for nursing licensure vary across dent nurses, registered nurses not currently employed or the countries examined, we assessed the education level retired, nursing assistants, registered/licensed practical according to whether the nurse had obtained the first oblig- nurses, and nurse practitioners. atory professional training in nursing (bachelors or diploma An invitation to complete the online questionnaire was in Ontario, Canada, and Hong Kong, China, and bachelors sent to nursing associations or other professional nursing in Sweden) or had obtained a higher level of education interest groups and through social media (e.g., professional (e.g., postgraduate specialization certificate, masters, PhD). Facebook groups, Twitter, WhatsApp). The invitation letter In total, eight practice areas were derived based on clinical had information about the study purpose, voluntary partici- specialty and workplace setting and included the following: pation, confidentiality of the data, and implied consent (a) pediatric care (e.g., pediatric emergency, pediatric from those who complete and submit the survey. The invi- oncology); (b) maternal care (e.g., obstetrics, neonatal tation included a request for respondents to complete the care); (c) geriatric care (e.g., gerontology, long-term care); survey only once. Snowball sampling was also used as a (d) general medicine/surgery, herein called medical-surgi- recruitment strategy, by asking respondents to recruit addi- cal (e.g., oncology, cardiology, surgery, operating theater); tional nurses (Patton, 2014). The invitation letter included a (e) critical/acute care (e.g., intensive care, emergency request for respondents to send the invitation and link to the department); (f) mental health care (e.g., psychiatry); (g) questionnaire to other registered nurses they knew who any direct care provided outside of hospitals (e.g., public were currently working, through Facebook contacts or health, primary care, home care, community nursing); and other electronic means (Sadler et al., 2010). A target sample (h) nondirect care (e.g., care coordination, research, educa- size was estimated using rules of thumb for descriptive tion, administration). research based on population size because effect sizes for differences in the countries selected were unknown (Hill, Families’ Importance in Nursing Care—Nurses’ Attitudes (FINC- 1998). A sample of 385 per country was selected as returns NA) Questionnaire. The FINC-NA questionnaire was the out- in power for increased sample size begin to plateau at this come measure. FINC-NA is a 26-item questionnaire number (Hill, 1998). originally developed in Sweden by Benzein and colleagues that measures the attitudes of nurses toward the importance of involving families in nursing care (Benzein, Johansson, Ethical Considerations Arestedt, Berg, & Saveman, 2008). The FINC-NA question- Ethics approval was obtained from the University of Toronto, naire has four subscales: family as a resource in nursing care Ontario, Canada (Reference #37882), the Hong Kong (Fam-RNC) with 10 items, score range 10 to 50, assesses Polytechnic University’s Research Ethics Board (Reference positive attitudes toward family members and the value of #: HSEARS20190520001), and the Swedish Regional Board their presence in nursing care (e.g., “Family members should of Ethics (Reference 2018/1535-31). The survey was volun- be invited to actively take part in the patient’s nursing care”); tary, confidential, and anonymous. family as a conversational partner (Fam-CP) with eight 72 Journal of Family Nursing 28(1) items, score range 8 to 40, assesses attitudes toward the Scores for the FINC-NA were calculated for the overall importance of acknowledging the patient’s family members scale and each subscale. Means and standard deviations were and having dialogue with them (e.g., “I ask family members used to describe the level of attitudes in each country. Means to take part in discussions from the very first contact, when a were compared using ANOVA followed by pairwise com- patient comes into my care”); family as a burden (Fam-B) parisons. Post hoc analyses were conducted using the with four items, score range 4 to 20, assesses negative atti- Bonferroni method with adjusted p values. This method of tudes toward the presence family members and time to take adjusting for multiple comparisons was selected due to the care of families (e.g., “The presence of family members small number of tests required. There were very little item- makes me feel that they are checking up on me”); and family level missing data (maximum/per item n = 3). When item- as its own resource (Fam-OR) with four items, score range 4 level missing data occurred, individual-level mean imputation to 20, assesses attitudes toward family members as having was used. their own resources for coping (e.g., “I consider family mem- Multiple linear regression was used to identify predictors bers as co-operating partners”; Benzein, Johansson, Arest- of the overall scale and each subscale. Predictors selected a edt, Berg, & Saveman, 2008). priori included country, age, gender, education, have had a In this study, the revised version of the FINC-NA ques- seriously ill family member in need of professional care, and tionnaire was used (Saveman et al., 2011). The English ver- practice area. Reference groups were selected based on the sion of the survey was used in Ontario, Canada, and Hong largest sample size to maximize power of comparisons. Kong, China, and the Swedish version of the survey was Model diagnostics were undertaken prior to establishing a used in Sweden. The Swedish version of the FINC-NA has final model, including tests of multicollinearity and assess- been validated with Swedish nurses (Benzein, Johansson, ing linearity of the relationship between age and the out- Arestedt, Berg, & Saveman, 2008; Saveman et al., 2011). come. Model fit was assessed using the F statistic and the The English version has been used in Canada showing good adjusted R . To determine whether predictors varied accord- internal consistency of the scales (Hoplock et al., 2019). In a ing to country, interaction terms were created by multiplying recent review, the revised FINC-NA was found to be one of dummy variables representing the three countries by each of the best suited questionnaires to measure the importance of the predictors. A model containing main effects only was family involvement in clinical practice (Alfaro Diaz et al., compared with a second model containing the main effects 2019). We referred to “family” as individuals considered sig- and interaction terms. An omnibus test of interaction was nificant for the patient, such as family members, friends, or undertaken testing all interaction terms at once using F neighbors (Benzein, Johansson, Arestedt, & Saveman, 2008). change statistic for each outcome of interest by comparing In their refinement of the scale, Saveman and colleagues the first model with the second. Nonsignificant interactions (2011) revised the item responses to a 5-point Likert-type were removed from the final model. Complete case analysis scale (ranging from 1 = strongly disagree to 5 = strongly was used because there were less than 5% missing data in the agree), replacing the original 4-point Likert-type scale final multivariable models and no reason to assume the data (Benzein, Johansson, Arestedt, Berg, & Saveman, 2008). were not missing at random. The analysis was undertaken Item scores are summed to create a total score that range using SPSS (V 26). from 26 to 130. After reverse coding negatively worded items from the Fam-B subscale, higher scores indicated more Results positive attitudes (i.e., perceived family as less of a burden). The revised FINC-NA has good internal consistency with Sample Characteristics Cronbach’s alpha .92 for the total scale and greater than .70 After removing a total of 10 cases with significant missing for the subscales (range: .72–.86; Saveman et al., 2011). In data (only a few questions were answered) or that did not this study, the internal consistency using Cronbach’s alpha meet the inclusion criteria (e.g., retired, nurse practitioner), for the total scale ranged from .92 to .94 and the subscales our final sample included a total of 740 nurses, with 164 ranged from .70 to .89 (with the exception of the Fam-B sub- from Ontario, Canada, 214 from Hong Kong, China, and 362 scale for Hong Kong, China, α = .62). from Sweden. The mean age ranged from 37 years in Hong Kong, China (SD = 10.9), 41 years in Ontario, Canada (SD Data Analysis = 13.2), and 42 years in Sweden (SD = 9.9). While most nurses in each country were females, the proportion of males The demographic characteristics of the sample were varied significantly across countries, from a low of 3.7% in described using summary statistics, such as means and stan- Ontario, Canada, to a high of 20% in Hong Kong, China (p dard deviations for continuous variables (e.g., age) and fre- < .001). At least a third of the sample from each country had quency counts and percentages for nominal variables (e.g., more than the first professional training requirement in nurs- gender). Characteristics were compared across the three ing (e.g., postgraduate specialization certificate, masters, countries using analysis of variance (ANOVA) and chi- PhD) with the greatest number coming from Sweden (42%), square tests, as appropriate. Cranley et al. 73 Table 1. Demographics of the Participants. Ontario, Canada (n = 164) Hong Kong, China (n = 214) Sweden (n = 362) Demographic n (%) n (%) n (%) Statistic p value Age—M (SD) 40.9 (13.2) 36.6 (10.9) 42.1 (9.9) 17.25 <.001 Missing (n) 8 2 0 Gender Female 155 (96.3) 156 (80.0) 338 (93.4) 34.35 <.001 Male 6 (3.7) 39 (20.0) 24 (6.6) Missing (n) 3 19 0 Education First diploma or degree 107 (66.5) 129 (60.3) 207 (57.8) 3.50 .176 Postgraduate education 54 (33.5) 85 (39.7) 151 (42.2) Missing (n) 3 0 4 Practice area Primary care/home/ 26 (16.1) 26 (12.9) 37 (10.2) 51.09 <.001 community care Critical care 34 (21.1) 16 (8.0) 54 (14.9) Geriatric care 17 (10.6) 22 (10.9) 43 (11.9) Maternal care 18 (11.2) 11 (5.5) 12 (3.3) Medical-surgical 33 (20.5) 85 (42.3) 109 (30.1) Mental health care 9 (5.6) 17 (8.5) 25 (6.9) Pediatric care 10 (6.2) 11 (5.5) 33 (9.1) Nondirect care 14 (8.7) 13 (6.5) 49 (13.5) Missing (n) 3 13 0 Seriously ill family member Yes 137 (83.5) 122 (57.0) 300 (82.9) 56.00 <.001 No 27 (16.5) 92 (43.0) 62 (17.1) Missing (n) 0 0 0 a b c Chi-square test for categorical variables and F test for continuous variables. First obligatory nursing diploma or degree. Postgraduate education (e.g., masters, PhD, postgraduate specialization certificate). Have had a seriously ill family member in need of professional care. although the proportion did not vary significantly across .001), or Sweden (M = 104.6, SD = 14.8; p <.001); how- countries. More than 80% of nurses from Ontario, Canada, ever, no significant difference was found between Ontario, and Sweden have had a seriously ill family member in need Canada, and Sweden (p = .171). Analysis of the subscale of professional care; this proportion was significantly higher scores showed significant cross-country differences for than that found in Hong Kong, China (57%; p < .001). Fam-B and Fam-CP subscales. The mean score for Fam-B Although the largest proportion of nurses from each country was highest (perceived family as less of a burden) in Sweden worked in a hospital medical-surgical unit, some variation in (M = 16.3, SD = 3.3), followed by Ontario, Canada (M = the distribution of practice areas was observed. For example, 14.3, SD = 3.6), and lowest in Hong Kong, China (M = a higher proportion of nurses worked in maternal care or 11.2, SD = 2.6), with significant differences being found critical/acute care in Ontario, Canada, than in the other coun- between each pair of countries (p < .001). The mean score tries, whereas more nurses worked in medical-surgical units for Fam-CP was significantly lower in Hong Kong, China (M in Hong Kong, China, and Sweden than in Ontario, Canada = 31.3, SD = 4.3), than in Ontario, Canada (M = 32.8, SD (see Table 1). = 4.7; p = .01), or Sweden (M = 33.1, SD = 5.3; p <.001); however, no significant differences were found between Ontario, Canada, and Sweden (p = 1.00). Objective 1. Cross-Country Differences in Nurses’ Attitudes Toward Families’ Importance in Nursing Objective 2a. Factors Associated With Nurses’ Care Attitudes Toward Families’ Importance in Nursing The mean levels of the FINC-NA total scale and subscales Care for each country are found in Table 2. The total score was significantly lower in Hong Kong, China (M = 97.0, SD = Prior to establishing the factors associated with nurses’ atti- 11.7), than Ontario, Canada (M = 102.1, SD = 14.0; p = tudes, the presence of interactions by country was tested to 74 Journal of Family Nursing 28(1) Table 2. Comparison of the Mean Score of the Families’ Importance in Nursing Care—Nurses’ Attitudes (FINC-NA) Questionnaire Using ANOVA Analysis. Ontario, Canada Hong Kong, China (n = 164) (n = 214) Sweden (n = 362) Omnibus F test Subscale M (SD) M (SD) M (SD) statistic p value Family as a resource in nursing care 39.4 (6.1) 38.9 (5.3) 39.5 (5.5) 0.67 .510 Family as a conversational partner 32.8 (4.7)a 31.3 (4.3)ab 33.1 (5.3)b 9.82 <.001 Family as a burden 14.3 (3.6)ac 11.2 (2.6)ab 16.3 (3.3)bc 169.71 <.001 Family as its own resource 15.7 (2.6) 15.6 (2.4) 15.8 (3.1) 0.15 .865 Total 102.1 (14.9)a 97.0 (11.7)ab 104.6 (14.8)b 19.94 <.001 FINC-NA scale Note. Fam-B = reverse scores. Pairwise differences are indicated with matching letters (e.g., within each row, the number with an “a” is significantly different from the number with a matching “a” in the same row); for example, the Fam-B row shows the mean for this subscale in Canada (14.3) is significantly different from the Fam-B mean for Hong Kong (11.2). ANOVA = analysis of variance. Fam-B = family as a burden. Table 3. Predictors of Nurse Attitudes Toward Families’ Importance in Nursing Care—Total Score. 95% CI 95% CI Predictor B Lower bound Upper bound p value Ontario, Canada −2.187 −4.704 0.330 .088 Hong Kong, China −4.739 −7.223 −2.256 <.001 Education 1.981 −0.117 4.078 .064 Gender −3.607 −7.049 −0.165 .040 Age 0.321 0.228 0.413 <.001 Seriously ill family −1.010 −1.373 3.393 .405 Primary care 2.382 −0.877 5.642 .152 Critical care −4.011 −7.187 −0.834 .013 Geriatric care 4.605 1.272 7.938 .007 Maternal care 5.548 1.058 10.038 .016 Mental health care 3.376 −0.709 7.462 .105 Pediatric care 5.218 1.631 8.806 .004 Nondirect care 9.607 5.630 13.583 <.001 F value 13.13 (13, 690) <.001 Adjusted r .18 Note. N = 704. The total score of Families’ Importance in Nursing Care—Nurses’ Attitudes was used as the dependent variable. Nonsignificant interactions between country and predictors were removed. CI = confidence interval. a b c d Country reference group = Sweden. Education reference group = first obligatory nursing diploma or degree. Gender reference group = female. Have had a seriously ill family member in need of professional care. Primary care/home/community care; practice area reference group = medical-surgical unit. ensure correct model specification. There was no evidence 95% confidence interval [CI] = [−7.2, −2.3]; p ≤ .001). that incorporating interactions between each of the factors Males had significantly lower scores (B = −3.6, 95% CI = and country into the model improved fit for the total scale or [−7.0, −0.2]; p = .04), while age was associated with any of the subscales, judged by nonsignificant F change val- higher scores (B = 0.3, 95% CI = [0.2, 0.4]; p ≤ .001). ues, F change (22, 668) = 0.12–1.3, p = .14–.59. As a result, Finally, various practice areas were found to have higher the interactions were removed from the model and Objective or lower scores than the reference group of medical-surgi- 2a was evaluated using main effects only. cal area. Nurses working in critical care had lower total The final model of predictors of nurses’ attitudes toward scores (less positive attitudes) on average (B = −4.0, 95% family importance in nursing care is shown in Table 3. For CI = [−7.2, −0.8]; p = .01), whereas those working in the total scale score, significant predictors of nurse atti- geriatric care, maternal care, pediatrics, and areas involv- tudes included country, age, gender, and several practice ing nondirect care (e.g., care coordination, academia) had areas, including critical care, geriatric care, maternal care, significantly higher scores than nurses working in medi- pediatric care, and nondirect care. After accounting for all cal-surgical areas. Taken together, the predictors accounted other variables in the model, scores in Hong Kong, China, for 18% of the variation in the total score of FINC-NA were significantly lower than those in Sweden (B = −4.7, (Table 4). Cranley et al. 75 Table 4. Predictors of Nurse Attitudes Toward Families’ Importance in Nursing Care—Subscale Scores. Fam-RNC Fam-CP 95% CI 95% CI 95% CI lower 95% CI upper Predictor B Lower bound Upper bound p value B bound bound p value Ontario, Canada −0.015 −1.047 1.018 .978 −0.258 −1.149 0.632 .569 Hong Kong, China 0.377 −0.641 1.396 .467 −0.760 −1.639 0.118 .090 Education 0.616 −0.244 1.476 .160 0.631 −0.111 1.373 .095 Gender −1.317 −2.729 0.094 .067 −1.848 −3.065 −0.631 .003 Age 0.096 0.058 0.134 <.001 0.099 0.066 0.132 <.001 Seriously ill family −0.450 −0.527 1.428 .366 −0.351 −0.492 1.193 .414 Primary care 1.107 −0.229 2.444 .104 0.751 −0.402 1.904 .201 Critical care −1.629 −2.931 −0.326 .014 −1.075 −2.198 0.049 .061 Geriatric care 1.827 0.461 3.194 .009 1.817 0.638 2.996 .003 Maternal care 1.937 0.096 3.778 .039 1.817 0.229 3.406 .025 Mental health care 0.816 −0.860 2.491 .339 1.790 0.345 3.235 .015 Pediatric care 1.448 −0.023 2.919 .054 1.850 0.581 3.119 .004 Nondirect care 3.706 2.075 5.336 <.001 3.087 1.680 4.493 <.001 F value 6.82 (13, 690) <.001 10.06 (13, 690) <.001 Adjusted r .10 .14 Fam-B Fam-OR 95% CI 95% CI 95% CI upper Lower 95% CI upper Predictor B Lower bound bound p value B bound bound p value Ontario, Canada −1.840 −2.429 −1.251 <.001 −0.064 −0.586 0.457 .808 Hong Kong, China −4.630 −5.212 −4.049 <.001 0.275 −0.240 0.790 .294 Education 0.327 −0.164 0.818 .191 0.410 −0.025 0.844 .065 Gender 0.017 −0.789 0.822 .967 −0.459 −1.172 0.255 .207 Age 0.081 0.059 0.103 <.001 0.045 0.025 0.064 <.001 Seriously ill family −0.217 −0.341 0.775 .446 0 −0.495 0.457 1.000 Primary care −0.045 −0.808 0.718 .907 0.573 −0.103 1.249 .096 Critical care −0.873 −1.616 −0.129 .021 −0.434 −1.093 0.224 .196 Geriatric care 0.476 −0.304 1.256 .231 0.495 −0.195 1.186 .160 Maternal care 0.084 −0.211 1.891 .117 0.954 0.023 1.885 .045 Mental health care 0.255 −0.701 1.211 .601 0.524 0.023 1.885 .225 Pediatric care 1.020 0.180 1.859 .017 0.899 0.155 1.642 .018 Nondirect care 1.047 0.117 1.978 .027 1.772 0.948 2.597 <.001 F value 35.42 (13, 690) <.001 5.31 (13, 690) <.001 Adjusted r .39 .07 Note. N = 704. The total score of Families’ Importance in Nursing Care—Nurses’ Attitudes was used as the dependent variable. Nonsignificant interactions between country and predictors were removed. Fam-RNC = family as a resource in nursing care; Fam-CP = family as a conversational partner; Fam-B = family as a burden (reverse scores); Fam-OR = family as its own resource; CI = confidence interval. a b c d Country reference group = Sweden. Education reference group = first obligatory nursing diploma or degree. Gender reference group = female. Have had a seriously ill family member in need of professional care. Practice area reference group = medical-surgical unit. The models of the predictors of each of the subscales are considered, attitudes of family as more of a burden (lower found in Table 4. Of the four subscales, the predictors scores) were found in Hong Kong, China (B = −4.6, 95% CI accounted for most variation in the Fam-B subscale (39%) = [−5.2, −4.1], p < .001), and Ontario, Canada (B = −1.8, and least variation in the Fam-OR subscale (7%). Age was a 95% CI = [−2.4, −1.3], p < .001), compared with Sweden. significant predictor across all four subscales (outcomes; p Practice area was associated with each of the subscales, < .001), while country was only associated with scores on but the pattern of association varied. In comparison with the Fam-B subscale. Once all model variables were medical-surgical areas, nurses working in geriatric care were 76 Journal of Family Nursing 28(1) associated with higher scores in the Fam-RNC and Fam-CP may be cross-country differences in health care/workplace subscales. Working in maternal care was also related to policies regarding the presence of family and their involve- higher scores in the Fam-RNC and Fam-CP subscales, as ment in care. well as higher scores in the Fam-OR subscale. Working in Nurses working in Hong Kong, China, had significantly mental health care was associated with higher scores in the less positive attitudes toward the importance of family in Fam-CP subscale, while working in pediatrics was associ- nursing care than nurses working in Ontario, Canada, or ated with higher Fam-B scores (perceived family as less of a Sweden. We located only one other study that compared nurse burden), as well as higher scores in the Fam-CP and Fam-OR attitudes across several countries in their sample (Luttik et al., subscales. By contrast, working in critical care was associ- 2017). Luttik and colleagues (2017) found that nurses work- ated with lower scores (less positive attitudes) in the Fam-B ing in Scandinavian countries (i.e., Denmark, Norway, subscale and lower scores in the Fam-RNC subscale. Sweden) had more positive attitudes than nurses in Belgium. Working in nondirect care was consistently associated with As noted, there may be differences between countries in fam- more positive attitudes in all subscales. Finally, being male ily involvement in nursing care (Luttik et al., 2017). was associated with lower scores in the Fam-CP subscale (B While the proportion of male respondents was low over- = −1.8, 95% CI = [−3.1, −0.6], p = .003). Education level all, and particularly in Ontario, Canada, we found that gen- and having had a seriously ill family member in need of pro- der had an effect on the overall scores. This was largely fessional care were not significantly associated with any of derived from the Fam-CP subscale, where men were found the outcomes examined. to have less positive attitudes about family as a conversa- tional partner than women. Studies conducted in Sweden similarly found that men had less supportive attitudes for Objective 2b. Differences in Predictors by Country family as a conversational partner (Benzein, Johansson, The lack of evidence supporting the presence of statistical Arestedt, & Saveman, 2008; Linnarsson et al., 2014). interaction suggests that the effects of the predictors on Gender differences where men had less positive attitudes nurses’ attitudes were similar across the countries tested. than women have also been reported for the subscales Fam- RNC (Benzein, Johansson, Arestedt, & Saveman, 2008) and Fam-OR (Linnarsson et al., 2014; Sveinbjarnardottir Discussion et al., 2011). While it is not clear why these gender differ- To our knowledge, this is one of the first studies to examine ences exist, these findings may be due to cultural differ- nurses’ attitudes about the importance of family involvement ences between countries, or differences between male and in nursing care across all health care settings from an interna- female communication styles. In a review of studies exam- tional perspective. Our study objectives were to describe and ining gender differences in health care provider-patient compare the level of nurse attitudes of the importance of communication in medical encounters, Street (2002) noted family in nursing care across three countries; to identify pre- that research has suggested that men and women tend to dictors of nurse attitudes toward family importance in nurs- have different communication styles, which is associated ing care; and to determine whether predictors vary by with one’s socialization (e.g., gender roles, cultural norms, country. We found that country, age, gender, and practice values, beliefs, attitudes). For example, female health care area were significant predictors, and that all model predictors providers may be more interpersonally and relationally ori- accounted for 18% of the total variation in nurses’ overall ented such as building partnerships with patients than male attitudes (total scores) toward the importance of family in health care providers (Street, 2002). In a recent study nursing care. In the model of Fam-B, the predictors accounted exploring male nurses’ views of gender in the nurse-family for nearly 40% of the variation, a much higher percentage relationship in pediatric care, male nurses described how than that accounted for in the overall scale or the other sub- they exerted more control over the boundaries of relation- scales. Significant predictors of family as a burden included ships with families including limiting their emotional country, age, and practice areas. Examining the standardized involvement than their female colleagues (Arreciado regression coefficients, the effect of working in Hong Kong, Marañón et al., 2019). Street (2002) highlighted that one’s China, compared with Sweden was much larger relative to attitudes toward men and women may generate assump- the other model effects with family as a burden as the out- tions or gender-based beliefs about the capabilities and come; however, with the other subscales as outcomes, the needs of conversational partners. However, other studies relative difference in effects was much smaller. A similar pat- found no association between gender and nurses’ attitudes tern was also found for the effect of working in Ontario, toward the importance of family involvement in nursing Canada, compared with Sweden. By contrast, the effect size care (Alguire, 2013; Hoplock et al., 2019; Luttik et al., of age and practice area relative to the other model effects 2007). Ethnicity, age, and other factors including the was more consistent across all the models of the subscales. broader context of health care (e.g., political, cultural) may This suggests that the effect of country is more apparent in also influence communication patterns and interactions relation to attitudes of family as a burden, highlighting there (Street, 2002). Cranley et al. 77 Practice area was a significant predictor of nurses’ atti- of family in critical care and pediatric care have found that tudes. On average, nurses working in critical care had sig- health care professionals have positive attitudes toward fam- nificantly less positive attitudes about the importance of ily involvement in routine care, but they had less supportive family in nursing care overall compared with those working attitudes toward family presence during resuscitation efforts in medical-surgical areas. Those in practice areas of geriatric in critical care (Al Mutair et al., 2014) or complex, technical care (e.g., long-term care), maternal care, pediatrics, and tasks in the care of hospitalized children (Power & Franck, nondirect care had significantly more positive attitudes com- 2008). Studies examining health care professionals’ attitudes pared with the medical-surgical practice area. Practice areas toward family involvement in care have focused on specific were also associated with each of the subscales. For exam- care situations such as family presence during resuscitation ple, in comparison with nurses working in medical-surgical and other invasive procedures (Al Mutair et al., 2014). Liput units, nurses working in maternal care had more positive atti- and colleagues (2016) conducted a literature review that tudes about family as a resource in nursing care, family as its explored both health care professionals and family attitudes own resource, and family as a conversational partner. Nurses toward involvement in intensive care and found that they working in geriatric care, pediatrics, and mental health also share an attitude that a partnership is essential to provide reported more positive attitudes toward family as a conversa- optimal care. Strategies are needed such as education and tional partner. Nurses working in pediatrics and in nondirect training programs to facilitate family integration into the care roles perceived families as less of a burden. Previous model of care (Al Mutair et al., 2014; Liput et al., 2016). studies examining various specializations or work settings In this study, the education level was not a significant pre- have reported differences in nurse attitudes. For example, dictor of nurses’ attitudes toward family importance in nurs- intervention studies conducted in Iceland have reported vari- ing care. While this finding is consistent with previous ation in nurse attitudes between different psychiatric units research (Hoplock et al., 2019; Linnarsson et al., 2014), (Sveinbjarnardottir et al., 2011), and between outpatient and other studies reported an association between higher educa- day surgery departments and inpatient departments (Blondal tion level and more positive attitudes (Gusdal et al., 2017; et al., 2014). Hagedoorn et al., 2020; Luttik et al., 2017; Østergaard et al., Studies comparing hospital settings with home care or 2020; Sveinbjarnardottir et al., 2011). However, we assessed primary health care have been mixed. Researchers have education based on the first professional training require- found that nurses working in home care (Hagedoorn et al., ment in nursing (diploma or bachelor’s degree) and a higher 2020) or primary health care (Benzein, Johansson, Arestedt, level of postgraduate education (e.g., master’s, PhD) and the & Saveman, 2008; Gusdal et al., 2017; Hagedoorn et al., requirements for basic licensure varied across countries. 2020; Østergaard et al., 2020) reported more positive atti- Studies examining the impact of an education or training tudes than those working in hospitals. However, Hoplock intervention for nurses on the importance of involving fam- et al. (2019) reported no differences in nurses’ attitudes ily in care have shown that nurses perceived families as less among hospital and home care settings. In this study, there burdensome following training (Sveinbjarnardottir et al., were no significant differences in attitudes toward the impor- 2011; Yamazaki et al., 2017), and nurses’ understanding of tance of family in nursing care between nurses working in the importance of family in care was strengthened (Yamazaki primary care/home/community care compared with those et al., 2017). While Blondal et al. (2014) reported no differ- working in medical-surgical areas. ences in nurses’ attitudes before and after their educational Nurses working in nondirect care roles reported more intervention, they suggested tailoring interventions to prac- positive attitudes across all four subscales. Nurses in these tice areas. Including a control group in intervention studies roles may experience family involvement in care differently. may also be warranted. Interventions such as education or This finding is consistent with other studies that have training that are tailored to the practice area, and aim to reported more positive attitudes among researchers (Luttik develop skills and competencies in communicating and col- et al., 2017), educators, and managers (Alguire, 2013; Luttik laborating with families as active partners in the care pro- et al., 2017). As noted by Alguire (2013), nurses in roles such cess, are approaches that could support family-focused care as a manager or educator tend to spend less time at the bed- (Benzein, Johansson, Arestedt, & Saveman, 2008; Hoplock side, which limits their exposure to families and may explain et al., 2019; Hsiao & Tsai, 2015; Linnarsson et al., 2014; more positive attitudes. Luttik and colleagues (2017) further Luttik et al., 2017; Østergaard et al., 2020). For example, the noted that it can be difficult to implement a family-focused International Family Nursing Association (IFNA, 2015) out- approach in clinical practice, particularly when there are lined nurse competencies for generalist family nursing prac- time constraints or a lack of experience with involving fami- tice centered around five core competencies: lies in care (Benzein, Johansson, Arestedt, & Saveman, 2008). Actively involving family in care requires support (1) enhance and promote family health; (2) focus family nursing from the team including nurses, physicians, and other health practice on families’ strengths/ the support of family and care professionals (Liput et al., 2016). Studies examining individual growth/ the improvement of self-management abilities/ the facilitation of successful life transitions/ the health care professionals’ attitudes toward the involvement 78 Journal of Family Nursing 28(1) improvement and management of health/ the moblilzation of Research that examines nurse attitudes toward family family resources; (3) demonstrate leadership and systems involvement in care in long-term care settings could inform thinking skills to ensure the quality of nursing care with families targeted interventions in this setting. New and innovative in everyday practice and across every context; (4) commit to ways to involve families in care should be explored. self-reflective practice with families; and (5) practice using an evidence-based approach. (p. 3) Limitations Mentorship programs for novice nurses and manager sup- Our study provides a comprehensive understanding of nurse port for allocating dedicated time for nurses to establish attitudes toward the importance of family in nursing care trusting relationships with patients and family members from across all health care sectors in Hong Kong, China, could also contribute to meaningful family involvement in Ontario, Canada, and Sweden. However, there are limita- nursing care (Benzein, Johansson, Arestedt, & Saveman, tions to note. We used a convenience sample including snow- 2008; Gusdal et al., 2017; Hsiao & Tsai, 2015). Other modi- ball sampling which may affect results; for example, people fiable factors of the work environment such as ensuring that are connected by social media to people who tend to hold the best practice guidelines, policies (e.g., visitor policies), and same views. While accessing potential participants through workplace philosophies are in place that encourage family online social media can be a feasible and effective recruit- involvement in care are additional strategies that may sup- ment strategy (Whitaker et al., 2017), only nurses with access port family involvement in care (Hoplock et al., 2019). to online nursing professional groups and other online nurs- Providing client- and family-centered care is an entry- ing interest groups or social media groups had access to the level competency for registered nurses in the three countries survey. However, online data collection allows participants included in our sample (College of Nurses of Ontario, 2018; to complete the survey at their convenience, and data are The Nursing Council of Hong Kong, 2012; Swedish Nurses’ anonymous. While participants were invited to complete the Association, 2017). However, the content and amount of survey only one time, we cannot ensure that participants training in family-centered care varies across these nursing completed the survey only once. The use of representative programs, and family-centered care may not be well inte- samples in future research will be important to validate our grated into all practice areas (Hsiao & Tsai, 2015). Gaining model findings and demonstrate generalizability to wider an understanding about differences between countries in nursing populations. regard to attitudes toward family nursing has implications Sample sizes varied across countries, and in two of the for both practice (e.g., learning from other countries’ health three countries, the target sample size was not met despite care systems, policies) and education (e.g., understanding the use of best practices of internet recruitment and a long how nurses are trained to fulfill the core competencies out- recruitment period. Our data collection period and partici- lined by the IFNA, 2015). pant recruitment coincided with social unrest in Hong Kong, Future research should seek perspectives from various China, and it overlapped with the onset of COVID-19 in stakeholders such as registered/licensed practical nurses, spring 2020. As the statistical power of a comparison was nurse practitioners, other health care professionals, and fami- determined by the smallest sample size, cross-country com- lies for a more comprehensive understanding of attitudes and parisons with Ontario, Canada, had less power to detect a factors that may contribute to family involvement in nursing difference. In addition, as sample sizes to test interactions are care (Blondal et al., 2014; Hoplock et al., 2019). Research smaller than those for main effects, the power to detect inter- should further explore nurse attitudes toward family impor- actions was also limited due to smaller sample sizes in tance in care between direct clinical practice roles and nondi- Ontario, Canada, and Hong Kong, China, compared with rect nursing roles. Aside from the study conducted in Sweden. Future research should obtain samples across coun- Belgium and Scandinavian countries by Luttik and col- tries that are large and similar in size. Ideally, more countries leagues (2017), we located no other studies that examined would be included so that between-country variation would nurse attitudes of family importance in care from an interna- be better understood using multilevel models. In this study, tional perspective. Research should further explore cross- we could not determine the nature of the cross-country dif- country differences in nurse attitudes, as well as the role of ferences. For example, these could reflect different health culture in nurse attitudes toward family involvement in nurs- care policy environments or differences in cultural values. A ing care (Luttik et al., 2017). Knowing where cross-country recent qualitative study reported that factors such as the differences occur could inform targeted interventions and organizational environment, the patient’s condition, and the provides areas of research for future international compara- nurse’s attitudes and perceptions of family were factors that tive studies. Qualitative studies exploring cultural or cross- resulted in variation in practices for involving families in country differences may provide additional insights. care in intensive care units (Naef et al., 2021). However, To our knowledge, ours is the first study using the the manner in which nurses involve families in care is not FINC-NA to examine nurse attitudes toward family impor- well understood (Misto, 2018; Naef et al., 2021). Future tance in care that has included long-term care settings. studies making cross-country comparisons should explore Cranley et al. 79 the cultural, relational, and organizational context (e.g., and health care system-level factors that may contribute to organizational policies for family involvement in care, nurses’ attitudes toward the importance of family in nursing guidelines) with regard to nurses’ attitudes and the role of the care. family in nursing care (Naef et al., 2021). We only surveyed nurses in Ontario, Canada. While Acknowledgments Ontario is the most populous province in Canada, the sample We thank Ms. Lauren MacEachern (PhD student, Institute of Health size was low and it provides only a snapshot of one province Policy, Management and Evaluation, Dalla Lana School of Public within Canada. There were a low number of males included Health, University of Toronto) for conducting the literature review in the study, particularly in Ontario, Canada. This would for this article. We also wish to thank the nurses who participated in have reduced the power to detect gender effects, but also this study. interactions between gender and country. Future research should focus on obtaining a larger sample of male nurses to Declaration of Conflicting Interests better understand the effect of gender, and use a qualitative The author(s) declared no potential conflicts of interest with respect approach to explain gender differences in attitudes toward to the research, authorship, and/or publication of this article. the importance of family in nursing care. The internal consistency for the Fam-B subscale for Hong Funding Kong, China, was lower (α = .62) than that for the other two The author(s) received no financial support for the research, author- countries, suggesting that some items may be heterogeneous. ship, and/or publication of this article. Previous studies have reported a Cronbach’s alpha of <.70 for the Fam-B subscale (Benzein, Johansson, Arestedt, & Availability of Data and Materials Saveman, 2008; Blondal et al., 2014; Linnarsson et al., No data sets are available from this study as it is outlined in the 2014). As Blondal et al. (2014) noted, because this subscale protocol that only the research team will have access to the data. contains fewer items (four items), a Cronbach’s alpha of .60 or greater is acceptable (Nunnally & Bernstein, 1994). The ORCID iDs FINC-NA has not been previously tested in Hong Kong, Lisa A. Cranley https://orcid.org/0000-0002-3308-7558 China. Moreover, the FINC-NA has not, to our knowledge, Simon Ching Lam https://orcid.org/0000-0002-2982-9192 been tested for measurement invariance across languages; therefore, comparison of the mean scores needs to be done Anne-Marie Boström https://orcid.org/0000-0002-9421-3941 with some caution. Future international work using this instrument should be preceded by formal testing of measure- Supplemental Material ment invariance across languages to provide stronger evi- Supplemental material for this article is available online. dence of cross-national differences. In addition, we developed an education variable for which the requirements for basic References licensure varied across countries. Finally, categories of prac- Ajzen, I., & Fishbein, M. (2000). Attitudes and the attitude–behav- tice areas were developed in an effort to be consistent and ior relation: Reasoned and automatic processes. European these may not have corresponded exactly across the three Review of Social Psychology, 11(1), 1–33. https://doi. countries. However, including nurses working in a variety of org/10.1080/14792779943000116 practice areas across health care settings may increase the Alfaro Diaz, C., Esandi, N., Gutierrez-Aleman, T., & Canga- generalizability of our study findings. Armayor, A. 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Cranley, RN, PhD, is an assistant professor, Lawrence S. Advanced Nursing, 62(6), 622–641. https://doi.org/10.1111/ Bloomberg Faculty of Nursing, University of Toronto, Canada. Her j.1365-2648.2008.04643.x research interest is in models of care to support quality health care Sadler, G. R., Lee, H. C., Lim, R. S., & Fullerton, J. (2010). delivery in the long-term care sector. Her research focuses on Recruitment of hard-to-reach population subgroups via adap- unregulated health care providers’ scope of practice, older adult and tations of the snowball sampling strategy. Nursing & Health family engagement in care, and uptake of best practices in long- Sciences, 12(3), 369–374. https://doi.org/10.1111/j.1442- term care. She currently leads an intervention study to support older 2018.2010.00541.x adults and family caregivers’ engagement in care planning. Recent Saveman, B. I. (2010). Family nursing research for practice: The publications include “Understanding Professional Advice Networks Swedish perspective. Journal of Family Nursing, 16(1), 26–44. in Long-Term Care: An Outside-Inside View of Best Practice https://doi.org/10.1177/1074840709360314 Pathways for Diffusion” in Implementation Science (2019, with J. Saveman, B. I., Benzein, E., Engstrom, A. H., & Arestedt, K. M. Keefe et al.), “Strategies to Facilitate Shared Decision-Making (2011). Refinement and psychometric reevaluation of the in Long-Term Care” in International Journal of Older People instrument: Families’ Importance in Nursing Care—Nurses’ Nursing (2020, with S. Slaughter et al.), and “Expanding the Attitudes. Journal of Family Nursing, 17(3), 312–329. https:// Concept of End-of-Life Care in Long-Term Care: A Scoping doi.org/10.1177/1074840711415074 Review Exploring the Role of Health care Assistants” in Shamali, M., Konradsen, H., Stas, L., & Ostergaard, B. (2019). International Journal of Older People Nursing (2020, with D. Just, Dyadic effects of perceived social support on family health and H. O’Rourke, W. B. Berta, & C. Variath). family functioning in patients with heart failure and their near- est relatives: Using the actor-partner interdependence media- Simon Ching Lam, RN, PhD, FHKAN, is an assistant professor of tion model. PLOS ONE, 14(6), Article e0217970. https://doi. The School of Nursing and Deputy Director of Squina International org/10.1371/journal.pone.0217970 Centre for Infection Control, The Hong Kong Polytechnic Street, R. L. (2002). Gender differences in health care provider- University, Hong Kong SAR. His research focuses on the field of patient communication: Are they due to syle, stereotypes, or infection control, psychometric testing, and care of older adults. accommodation? Patient Education and Counseling, 48(3), Currently he is leading a project in establishing a testing certified 201–206. https://doi.org/10.1016/s0738-3991(02)00171-4 laboratory for assessing the quality of facemask and filtering mate- Sveinbjarnardottir, E. K., Svavarsdottir, E. K., & Saveman, B. I. rial as well as developing a new Chinese-specific N95 respirator, (2011). Nurses attitudes towards the importance of families in which both of these are important in the COVID-19 pandemic. psychiatric care following an educational and training inter- Recent publications include “Observational Study of Compliance vention program. Journal of Psychiatric and Mental Health With Infection Control Practices Among Healthcare Workers in Nursing, 18(10), 895–903. https://doi.org/10.1111/j.1365- Subsidized and Private Residential Care Homes” in BMC Infectious 2850.2011.01744.x Diseases (2021, with J. K. L. Au & L. K. P. Suen), “Global Swedish Nurses’ Association. (2017). Competence description Imperative of Suicidal Ideation in Ten Countries Amid the COVID- for a licensed nurse. swenurse.se/publikationer/kompetens- 19 Pandemic” in Frontiers in Psychiatry (2021, with T. Cheung beskrivning-for-legitimerad-sjuksköterska et al.), and “Face Mask Wearing Behaviors, Depressive Symptoms, Voltelen, B., Konradsen, H., & Østergaard, B. (2016). Family nurs- and Health Belief in Older People During the COVID-19 Pandemic” ing therapeutic conversations in heart failure outpatient clinics in Frontiers in Medicine (2021, with R. Y. C. Kwan, P. H. Lee, & in Denmark: Nurses’ experiences. Journal of Family Nursing, D. S. K. Cheung). 22(2), 172–198. https://doi.org/10.1177/1074840716643879 von Elm, E., Altman, D. G., Egger, M., Pocock, S. J., Gotzsche, Sarah Brennenstuhl, PhD, is an analyst and health researcher at P. C., & Vandenbroucke, J. P. (2007). STROBE initiative. the Lawrence S. Bloomberg Faculty of Nursing, University of The Strengthening the Reporting of Observational Studies in Toronto, Canada. She has advanced training in statistical methods Epidemiology (STROBE) statement: Guidelines for reporting and specializes in analysis of health inequalities and methods for observational studies. British Medical Journal, 355, 806–808. understanding the influence of distal factors on health status. Recent https://doi.org/10.1136/bmj.33335.541782.AD https://www. publications include “Researching the Health of Mothers of Young bmj.com/content/335/7624/806 Children Using Comparative Research Methods and Secondary Whitaker, C., Stevelink, S., & Fear, N. (2017). The use of Facebook Analysis of Population-Based Data” in SAGE Research Methods in recruiting participants for health research purposes: A sys- Cases (2020), “Development and Psychometric Evaluation of the tematic review. Journal of Medical Internet Research, 19(8), Preconception Health Knowledge Questionnaire” in American e290. https://doi.org/10.2196/jmir.7071 Journal of Health Promotion (2021, with Z. Cairncross et al.), and Wright, L. M., & Leahey, M. (1990). Trends in the nursing of fami- “A Comparison of Educational Events for Physicians and Nurses in lies. Journal of Advanced Nursing, 15(2), 148–154. https://doi. Australia Sponsored by Opioid Manufacturers” in PLOS ONE org/10.1111/j.1365-2648.1990.tb01795.x (2021, with Q. Grundy, S. Mazzarello, & E. Karanges). 82 Journal of Family Nursing 28(1) Zarina Nahar Kabir, PhD, is an associate professor of Public Health Angela Yee Man Leung, PhD, MHA, BN, RN, FHKAN at the Division of Nursing, Department of Neurobiology, Care (Gerontology), is a professor, Director of the Centre for Sciences and Society at Karolinska Institutet, Sweden. Her research Gerontological Nursing (CGN), and Deputy Director of WHO focuses on aging, family caregiving, mental health, and use of tech- Collaborating Centre for Community Health Services in the School nology in health care. She is currently leading an intervention study of Nursing of Hong Kong Polytechnic University. She is also the using mHealth to support family caregivers of persons with demen- Theme Leader of research theme “Aging and Health” in the School tia. She is also a coinvestigator of a rapid response survey on COVID- of Nursing. She is an active researcher in health literacy and demen- 19 in Bangladesh. Recent publications include “In Conversation tia caregiving, with a wide range of publications in international With a Frontline Worker in a Care Home in Sweden During the journals. Recent publications include “Care of Family Caregivers COVID-19 Pandemic” in Journal of Cross-Cultural Gerontology of Persons With Dementia (CaFCa) Through a Tailor-Made Mobile (2020, with A. M. Boström & H. Konradsen) and “Care of Family App: A Study Protocol of a Complex Intervention Study” in BMC Caregivers of Persons With Dementia (CaFCa) Through a Tailor- Geriatrics (2020, with Z. N. Kabir et al.), “A Mobile App for Made Mobile App: A Study Protocol of a Complex Intervention Identifying Individuals With Undiagnosed Diabetes and Prediabetes Study” in BMC Geriatrics (2020, with A. Y. M. Leung et al.). and Changing Behavior: 2-Year Prospective Study” in Journal of Medical Internet Research (2018, with X. Y. Xu et al.), and Anne-Marie Boström, RN, PhD, is an associate professor in “Behavioural Activation for Family Dementia Caregivers: A Nursing at Karolinska Institutet and Director for Nursing Systematic Review and Meta-Analysis” in Geriatric Nursing Development at Karolinska University Hospital, Theme Aging and (2020, with X. Y. Xu & R. Y. C. Kwan). Inflammation, Huddinge in Sweden. Her research focuses on health and well-being for older persons with or without dementia, and she Hanne Konradsen, RN, PhD, is a professor in clinical nursing at is also conducting research on the dissemination and implementa- Herlev and Gentofte University Hospital and University of tion of research findings and evidence in the care of older adults. Copenhagen in Denmark and an associate professor at Karolinska She is Principal Investigator for the Older Person’s Exercise and Institute in Sweden. Her research is focused on the interplay Nutrition (OPEN) study and is participating in an intervention study between innovation and nursing. Currently she is participating in a to evaluate the effect of support using a mobile application to a fam- study on the effect on family support mediated by a mobile applica- ily member caring for a person with dementia at home. Recent pub- tion, the use of virtual reality in caring for children, and how best to lications include “Response and Adherence of Nursing Home use hospital design to optimize the effect of nursing. Recent publi- Residents to a Nutrition/Exercise Intervention” in Journal of the cations include “Providing Dementia Care Using Technological American Medical Directors Association (2021, with E. Karlsson Solutions: An Exploration of Caregivers’ and Professionals’ et al.), “A Learning Process Towards Person-Centred Care: A Experiences of Using Technology in Everyday Life With Dementia Second Year Follow-Up of Guideline Implementation” in Care” in Journal of Clinical Nursing (2020, with S. Kristiansen, M. International Journal of Older People Nursing (2021, with K. Beck, & Z. N. Kabir), “The COVID-19 Pandemic: A Family Affair Kindblom, D. Edvardsson, & S. Vikström), and “Being Treated [Guest Editorial]” in Journal of Family Nursing (2020, with M. L. With Respect and Dignity? Perceptions of Home Care Service Luttik et al.), and “Factors Associated With Family Functioning in Among Persons With Dementia” in Journal of the American Patients With Heart Failure and Their Family Members: An Medical Directors Association (2021, with L. Marmstål Hammar, International Cross-Sectional Study” in Journal of Advanced M. Alam, M. Olsen, & A. Swall). Nursing (2021, with M. Shamali et al.)

Journal

Journal of Family NursingSAGE

Published: Sep 8, 2021

Keywords: nurse attitudes; family-focused care; survey; cross-sectional; cross-national comparisons

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