Family-centered care in the perioperative area: an international perspective

AORN Journal,  May, 2007  by Linda Shields

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The terms family-centered care and perioperative care are often heard health care, the first usually in relation to children--though it is beginning to be used with other age groups-and the other in relation to a particular area, the OR and perioperative environment. Family-centered care has not been formally evaluated to see if it really works, though it is commonly used by pediatric health professionals. (1) Perioperative care is care delivered to any patient who is having surgery. This article explains how both models have come about and examines the way the two interact, with the aim of exploring the way family-centered care can be delivered in the perioperative setting.

FAMILY-CENTERED CARE DEFINED Family-centered care can be defined as

   a way of caring for children and their
   families within health services which
   ensures that care is planned around
   the whole family, not just the individual
   child/person, and in which all
   the family members are recognized as
   care recipients. (2(p1318)

The Institute for Family-Centered Care in the United States suggests that family-centered care comprises several elements (3) (Table 1) based on the core concepts of

* dignity and respect;

* information sharing;

* patient and family member participation in care and decision-making; and

* collaboration among caregivers, patients, and family members. (4)

The term family-centered care has come to be widely used in pediatrics, though its attainability as a model of care is in question, (5,6) and its effectiveness has never been properly tested. (1)

HISTORICAL BACKGROUND OF FAMILY-CENTERED CARE

Until the 1950s, the concept of family-centered care would have induced horror in the minds of pediatric health professionals because parents were seen as a negative factor in the care of hospitalized children. (7) In the 1920s, Sir James Spence, an English pediatrician, was the first to contest the routine exclusion of the parent in the care of hospitalized children, admitting mothers with their infantsy though these practices were contested by other physicians. (10) In the 1940s, two plastic surgeons in New Zealand admitted mothers with their infants and showed that this did not increase infection rates, which was one of the arguments used for excluding parents. (11,12) Some disagreed with the practice of admitting mothers, going so far as to say that a mother would rather be home caring for her other children than sitting at the side of the bed of a child who would, in normal circumstances, not spend much time with his or her mother at all. (13) This study coined the term the "captive mother." (14(p362) Some physicians felt that parents inhibited the recovery of children, (7) but others advocated for parental presence. (15)

Although little empirical research into the topic by nurses was found from this era, many nurses were just as equivocal in their attitudes as their physician colleagues. Some nurses were pleased to have parents stay with their children, (16) others were not convinced that it was in the best interests of the child, (17) and some were hostile toward the idea. (18) Some nurses thought that a parent's presence undermined the relationship between nurse and child. (19) One nurse described ways to ameliorate the emotional trauma in children as a result of separation from their parents, but did not advocate that parents should stay with their children. (20)

Mother-child separation was the force at the heart of the controversy. At that time, it was almost invariably mothers to whom reference was made because mothers were the primary caregivers to children while fathers went out to work. In London during World War II, psychoanalysts Dorothy Burlingham and Anna Freud, (21,22) Sigmund Freud's daughter, studied the effects of separation in nurseries they ran for children who needed long-term care, usually due to the parents' involvement in war work. They found that young children who suffered physical trauma--for example, as a result of being in a house that was bombed--maintained psychological stability if they were with their mothers.

In America, Rene Spitz, another psychoanalyst, began using the term hospitalism to refer to the psychological and growth retardation suffered by infants who were left in the hospital for a long time without their mothers. (23) This institutionalization of the child and its effect on his or her psyche caused the child not to relate to his or her parents in a normal way. A surgeon, David Levy, (24,25) propounded that young children who had undergone surgery suffered less emotional trauma if their mothers accompanied them to the hospital.

Two British men were responsible for inaugurating the substantial changes that occurred in the care of hospitalized children during the next 30 years. Together, John Bowlby, a child psychiatrist and theorist, and James Robertson, a social worker, investigated the results of separation of child and parent. Bowlby described the negative effects of breaking the emotional ties between mother and child at an early age. (26,29) Robertson focused his work on separation of child and parent because of hospital admission (30) and proselytized about the need to allow parents to accompany their children to the hospital. (31,32) In 1959, the British government set up a select committee to examine the way children were treated in children's hospitals. The resulting document, known as the Platt Report, (33) was used by governments, parents' groups, and lobby organizations to bring about changes in pediatric care worldwide.