Patient care demands, the professional practice environment, and lack of resources hindered nursing family caregiver involvement, found a recent survey of 374 critical care nurses.1

“In the ICU, critical care nurses are key staff in promoting and supporting caregiver engagement in patient care,” says Breanna Hetland, PhD, RN, CCRN-K, the study’s lead author. Hetland is an assistant professor at the University of Nebraska Medical Center’s College of Nursing in Omaha.

Yet nurses’ individual perceptions and personal beliefs greatly influence their attitude toward engaging family caregivers in patient care. Ideally, interventions encourage collaborative partnerships between patients, families, and critical care nurses.

“It is imperative to understand the perceived barriers that critical care nurses face in regards to involving family caregivers in the patient’s care in the ICU,” says Hetland.

Approaches Linked to Many Factors

Researchers found that nurses’ approaches to family involvement were not only dependent on their personal beliefs. They also were linked to other factors related to the family, the patient, the professional practice environment, and available resources.

“The results of our study indicate a need to further examine factors such as staffing, space, and resources for families, and unit culture,” says Hetland. Establishing policies and procedures that outline the role of family caregivers also is important, she adds.

Nurses reported these obstacles to involving families:

• workload burden associated with the care of critically ill patients;

• an ICU culture that is unsupportive of family involvement;

• lack of policies and guidelines to enhance the practice;

• inadequate interprofessional and nursing leadership support.

“In addition, nurses had concerns about patient and family safety and legal repercussions,” says Hetland. “These were their rationales for limiting family involvement.”

Hetland says that some nurses did not know how to involve families. They posed questions about who should be involved and how they should be involved.

If nurses are expected to engage caregivers, says Hetland, “there must be readily available, evidence-driven policies and procedures, supported by current practice guidelines, to help standardize patient care.”

Conflicting Interests

Ethicists can create opportunities for goals of treatment discussions and advance care planning across the continuum of care. “This is one of the best ways to facilitate family-centered care,” says Tyler S. Gibb, JD, PhD, a clinical ethicist and co-chief in the program in medical ethics, humanities, and law at Western Michigan University Homer Stryker MD School of Medicine in Kalamazoo.

One of the primary concerns, from an ethical perspective, is balancing the disparate interests of the various stakeholders. Sometimes, these are in direct conflict.

“Particularly when establishing a goal of treatment, the team is forced to make value judgments about which interests to prioritize,” says Gibb.

Incomplete information is one of the biggest barriers to family involvement, says Gibb. This includes clearly articulated preferences or goals, diagnostic information, prognoses, and treatment efficacy.

All of these “are each unknowable to a greater or lesser degree in certain circumstances,” says Gibb. “Making ethically justifiable decisions without perfect information is always a challenge.”


1. Hetland B, McAndrew N, Perazzo J, et al. A qualitative study of factors that influence active family involvement with patient care in the ICU: Survey of critical care nurses. Intensive Crit Care Nurs 2018; 44:67-75.


• Tyler S. Gibb, JD, PhD, Assistant Professor, Clinical Ethicist/Co-Chief, Program in Medical Ethics, Humanities & Law, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo. Email:

• Breanna Hetland, PhD, RN, CCRN-K, Assistant Professor, College of Nursing, University of Nebraska Medical Center, Omaha. Phone: (402) 559-5460. Email: