Nursing students' perception of family importance in nursing care during the COVID-19 pandemic: A cross-sectional study.

BACKGROUND: Little is known about nursing students' illness beliefs and attitudes towards the involvement of families in nursing care during the COVID-19 epidemic. Focusing on family nursing throughout an undergraduate nursing education is not only appropriate or critical but also essential for advancing family nursing practice.
OBJECTIVES: To evaluate the differences in undergraduate and graduate nursing students' perceptions of illness beliefs and their family nursing practice skills at the time of the COVID-19 pandemic.
DESIGN: A cross-sectional study. SETTINGS: The Faculty of Nursing at the University of Iceland. PARTICIPANTS: Of the nursing and midwifery students, 109 participated in 2020 from one university.
METHODS: Data was collected regarding illness beliefs and attitudes towards family involvement in nursing care, through questionnaires via the Red Cap software.
RESULTS: The main finding indicated that the graduate students reported more confidence or reassurance regarding their knowledge of the cause of an illness, control, effect, suffering and what is the most and the least helpful in coping with an illness/health disorder when compared to the undergraduate students (t-value = -2.50, p-value = 0.014). Additionally, graduate nursing students also reported higher positive attitudes towards family importance in nursing care than undergraduate students (t-value = -2.16, p-value = 0.033).
CONCLUSION: Even though the graduate students reported higher illness beliefs than undergraduate students, the undergraduate students reported a reasonably high or over medium high score, on the illness beliefs scale. University nursing educators need to be aware that nursing students' knowledge, skills and attitudes towards family nursing practice at the time of the COVID-19 pandemic shape clinical competence in family nursing within health care settings.

Introduction

There has been a shift over the last decade in health care services, towards involving families in care delivery. The nursing profession has at the same time emphasized the importance of both patients and family-centered evidence-based care (EBC) because healthy development, disorders, illnesses, and crises affect not only patients but also their families (Alabdulaziz and Cruz, 2020; Cranley et al., 2021). Integrating individual and family care has also been found to improve the well-being of individuals and families (Chesla, 2010). Family system nursing (FSN), where the focus has been on the benefit of family support, educational and psycho-social nursing interventions, has additionally shown improvement in outcomes (Alfaro-Díaz et al., 2022; Benoot et al., 2020; Holst-Hansson et al., 2020). Nevertheless, clinical nurses report a lack of family involvement in health care delivery (Duhamel, 2017; Eggenberger and Sanders, 2016) and the need to have access to continuing education regarding how and in what way they can offer evidence-based family nursing care to their patients and their families (Gutiérrez-Alemán et al., 2021; McAndrew et al., 2020; Meiers et al., 2018).

Nurse practitioners have long been moved by the benefit of both short- and long-term family nursing education and support interventions for patients and families because of the positive impact the interventions have had on the illness experience (Holst-Hansson et al., 2020; Østergaard et al., 2021) as well as to be perceived to benefit a care delivery model by health care professionals in intensive care (Naef et al., 2020) and in palliative care (Petursdottir and Svavarsdottir, 2019). In general, these interventions have most often been offered by advanced nurse practitioners but less often by general nurse practitioners. The most frequent reasons given by general nurse practitioners' for not being able to involve families in their care include demands such as a lack of time and high workload, as well as other organizational and clinical practice barriers (Beierwaltes et al., 2020), which may hinder nurses in responding to the needs of families for support and education about the illness situation.

A major assumption of family nursing stated by the International Family Nursing Association (International Family Nursing Association (IFNA), 2013, International Family Nursing Association (IFNA), 2017) and by Wright and Bell (2021) is that health and illness concerns experienced by an individual have an impact on the whole family (Wright and Bell, 2021). Furthermore, family nursing educators have emphasized the importance of nursing students being aware of how illness beliefs can have an impact on health outcomes. Importantly, Wright and Bell (2021) have defined illness beliefs as a subset of overall beliefs, which can be viewed as the lenses that we view the world with, which guide the choices we make, the behaviors we revile and our connected feelings. In that way, family nursing offered by both generalists and advanced nurse practitioners requires the ability to continually integrate conceptual, perceptual, and executive competencies to meet the demands for both person-centered and family centered care (International Family Nursing Association (IFNA), 2013; Wright and Bell, 2021; Wright and Leahey, 2013).

However, Wright and Bell (2021) state they believe that when caring for and intervening with patients and their families, a skilled advanced family nurse practitioner needs to be willing to step into illness conversations, despite the discomfort that often arises, and to listen with deep compassion and curiosity to the patient and their family members' illness experiences (Wright and Bell, 2021). In this context, compassion, as explained by Wright (2017), is more than just the commitment to understand another person's experience; it is a longing and a wanting to soften suffering by being fully present and genuinely listening despite how difficult it might be for the advanced nurse practitioner to do so (Wright, 2017). The action of curious compassion also consists of staying “behind one's eyes” (Wright and Bell, 2021). In such a therapeutic moment, it means not multitasking or thinking ahead to other responsibilities that also need to be completed. When nurses are not fully present in their therapeutic conversations with patients and family members, suffering increases because of patients and family members' distress or pain and because their suffering is not being accepted or valued by the nurse practitioner (Wright and Bell, 2021).

Nevertheless, nurse educators are in a prime position to facilitate, motivate, inspire, and ease nursing students' understanding of how to apply and implement evidence-based family nursing research into practice (Alabdulaziz and Cruz, 2020; Saveman et al., 2005; Svavarsdottir et al., 2021). Furthermore, quality nursing practice with families can be established in academia (Swan and Eggenberger, 2021), but educators can both design simulation learning and guide students in developing relational skills needed to gain confidence in clinical settings as well as encouraging reflections (in classroom and in clinical training) on individual and family health (Bell, 2011; Swan and Eggenberger, 2021). At the Faculty of Nursing, School of Health Sciences at the University of Iceland, a new approach was taken up three years ago regarding teaching family nursing in the BSN program. In our undergraduate curriculum, the main emphasis in teaching family system nursing is on applying theoretical family nursing models and research into clinical practice, through lectures and through practicum training such as in skill lab training, relational simulation, as well as in clinical practice where the focus is on intervening with families dealing with normal developments, acute or chronic illnesses or with crises. Furthermore, in our graduate program, an elective advanced family nursing course is also offered to students. Nevertheless, in today's societies following the COVID-19 pandemic, it is still crucial to create new learning approaches in family health care, especially since families have in many places been omitted physically from health care service, but technical assistance used instead when communicating with family members, such as through secure video phone calls.

Nursing education during the COVID-19 pandemic has been challenging as students have not been able to physically attend classes, and clinical placements have often changed with little or no notice, giving students just a short time to adjust to distance learning and having their universities locked down. Little is known about nursing students' perceptions of their family nursing practice skills and their illness beliefs when caring for patients and their families at the time of the COVID-19 pandemic. Studies regarding the COVID-19 pandemic, however, have been published on the difficulty with learning at the time of the pandemic (Lovrić et al., 2020), on the importance of teaching nursing students healthy coping skills and on academic engagement to reduce stress and burnout (Wang et al., 2021).

The purpose of this study was to evaluate the difference in undergraduate and graduate nursing students' perceptions of illness beliefs and their family nursing practice skills at the time of the first wave of the COVID-19 pandemic.

Methods

Design, study population and procedure

The COVID-19 pandemic has significantly disrupted research among health care professionals because of social distancing, which has hindered participant recruitment, enrollment, and involvement in studies (Abshire et al., 2021). This study was a cross-sectional web-based study in which all students at the University of Iceland, Faculty of Nursing, were invited to participate through e-mail (N = 632). Data collection took place in March through April of 2020 at the time of the first wave of the COVID-19 pandemic and at the time of the first lockdown at the University of Iceland, which resulted in 109 undergraduate and graduate students´ participation, an 18 % participation ratio. Red Cap an electronic software was used to collect the data because it is a secure electronic data collection system. Data were collected through questionnaires. The students received the questionnaires through their university e-mail, with a link directing them to the REDCap questionnaires. A member of the research team (who is not a faculty member) contacted the students via their e-mail addresses which she received form a project manager. The study was open for 4 weeks, and the students received a weekly reminder regarding the study (for a total of 4 reminders). The first case of COVID-19 was diagnosed in Iceland on February 27, 2020, but in March throughout April, all universities in Iceland closed their facilities at campus and transitioned to online teaching if their programs were not already online.

Measures

Demographic characteristics

Background information (12 items) regarding the students' age, gender, educational level, marital status, etc., was collected via a questionnaire, from both the undergraduate and graduate students at the Faculty of Nursing, School of Health Sciences at the University of Iceland. The background information is presented in Table 1 .

Table 1

Demographic characteristics of undergraduate and graduate nursing students at the Faculty of Nursing, School of Health Sciences at the University of Iceland (N = 109).

Background variables	Undergraduate students (n = 64)		Graduate students (n = 45)
	n	%	n	%
Age
<20 years	1	1.7	0	0.0
21–25 years	34	56.7	1	2.4
26–30 years	20	33.3	5	11.9
31–35 years	3	5.0	5	11.9
36–40 years	1	1.7	7	16.7
41–45 years.	1	1.7	11	26.2
46–50 years	0	0.0	6	14.3
>50 years	0	0.0	7	16.7
Gender
Female	61	95.3	41	100
Male	3	4.7	0	0.0
Marital status
Single	25	39.1	8	18.2
Cohabiting	31	48.4	9	20.5
Married	3	4.7	25	56.8
Other	5	7.8	2	4.5
BSN nursing students
First year	10	16.4
Second year	9	14.8
Third year	14	23.0
Forth year	26	42.6
Between years	2	3.3
Graduate students
Diploma students			6	14.0
MS students/midwifery			30	69.8
PhD students			7	16.3
Are you working during your studies?
Yes	55	85.9	37	84.1
No	9	14.1	7	15.9
If yes, are you working in caregiving as a nursing student?
Yes	44	81.5	33	89.2
No	10	18.5	4	10.8
Do you think it is important to care for families within health care systems?
Yes	63	98.4	45	100
No	1	1.6	0	0.0
Have you taken a course in family nursing?
Yes	36	56.3	20	45.5
No	28	43.8	24	54.5
Are you interested in taking a course in family nursing?
Yes	25	89.3	14	58.3
No	3	10.7	10	41.7
Have you experienced that someone in your family has needed health care services because of an acute or a chronic illnesses or had an accident?
Yes	48	75.0	35	81.4
No	16	25.0	8	18.6
How satisfied are you in your studies?
Very or rather satisfied	54	84.4	42	93.3
Neutral	6	9.4	1	2.2
Rather or very unsatisfied	4	6.3	2	4.4

n varies because of missing data.

Illness beliefs

The Iceland Health Care Practitioner Illness Beliefs Questionnaire (ICE-HCP-IBQ) is a self-report measure with seven items using a 5-point Likert scale (1, Never to 5 all-of-the-time) and 5 open-ended questions, which were constructed and developed to measure illness beliefs among health care professionals regarding their beliefs when their patients and family members are dealing with or suffering from long-term illnesses or health problems (Svavarsdottir et al., 2018; Svavarsdottir et al., 2021). This questionnaire was developed from the Illness Beliefs Model (Wright and Bell, 2009) to measure illness beliefs referring to the cause of the illness/health problem, control, effect, suffering and perceived support. A higher score indicates more reassurance or confidence regarding health care professional beliefs. The instrument has one factor with a total Cronbach's alpha of 0.83–0.92 (Svavarsdottir et al., 2018) and has been found to be both valid and reliable. The 5 open-ended questions were not used in the analyses in this study.

Families' Importance in Nursing Care-Nurses' Attitudes (FINC-NA) questionnaire

The FINC-NA is a 26-item scale that was developed to measure the attitudes of nurses/nurses' students towards the importance of involving families in nursing care (Benzein et al., 2008). The questionnaire has four subscales: a) family as resource in nursing care (Fam-RNC), which assesses positive attitudes towards family members and the value of their presence in nursing care. This is a 10-item subscale, where the scores can range from 10 to 50. An example of a question is “family members should be invited to actively take part in the patient's nursing care”; b) family as a conversational partner (Fam-CP), assess attitudes towards the importance of acknowledging the patient's family members and having dialogue with them. The subscale is 8 items that range from 8 to 40; an example of a question is “I ask family members to take part in discussions from the very first contact when a patient comes into my care”; c) family as a burden (Fam-B) evaluates negative attitudes towards the presence of family members and time to take care of families. The subscale is four items that range from 4 to 20; an example is “the presence of family members makes me feel that they are checking up on me” and d) family as its own resource (Fam OR), assessing attitudes towards family members as having their own resources for coping. This is a four-item subscale ranging from 4 to 20, and an example item is “I consider family members as co-operating partners”. The instrument has been reported to be both valid and reliable. Cronbach's alpha has been reported to be 0.89–0.91 for the total scale and range from 0.65 to 0.86 for the subscales (Saveman et al., 2011).

Ethical consideration

The study design and procedure were approved by the dean of the Faculty of Nursing at the School of Health Sciences at the University of Iceland and by the National Bioethics Committee (approval number: 20-053). Participants received a letter explaining the purpose of the study, the methods, the questionnaires and the policy that students could withdraw from the study until the analysis of the data. Furthermore, contact persons were identified in the letter so that the students could contact them if they had any questions/concerns regarding the study.

Data analysis

Statistical analysis was carried out using Statistical Package for the Social Sciences 24.0 (SPSS Inc., Chicago, IL, USA). All categorical variables were decoded as dichotomous and presented as such. Descriptive data are presented as the means, standard deviations and percentages. Independent t-tests were used to test differences between groups. If 80 % or more responses were replied to, mean scores were used to create the total scale score.

Results

Descriptive findings

The majority of the undergraduate students ranged in age from 20 to 30 years, while most of the graduate students were between 31 and over 50 years. All of the graduate students (100 %) and the majority of the undergraduate students were female (95 %), and approximately half of the undergraduate and most of the graduate students were either cohabiting (uns = 48 %; gns = 21 %) or married (uns = 5 %; gns = 57 %). Of the undergraduate students, approximately 2/3 were either students in the 3rd or the 4th year of their BSN study, and most of the graduate students were master's students (Table 1).

Mean differences in illness beliefs and attitudes towards involving families in nursing care

There was a significant difference in illness beliefs between the undergraduate and the graduate nursing students (p < 0.05), indicating that the graduate students reported more confidence or reassurance regarding their knowledge of the cause of an illness, control, effect, suffering and what is the most and the least helpful to cope with an illness or health disorder (Table 2 ). Furthermore, the graduate nursing students also reported significantly higher positive attitudes towards family importance in nursing care (total scale) than undergraduate students (p < 0.05) (Table 2). Additionally, the graduate nursing students also reported significantly higher perception of the family as a conversational partner (Fam-CP) than the undergraduate students (p < 0.05) and of the family as its own resource (Fam-OR) (p < 0.05) and reported significantly less perception of the family as a burden in caregiving (Fam-B) (p < 0.001) (Table 2).

Table 2

Comparison of undergraduate (n = 64) and graduate nursing students (n = 45) illness beliefs and attitudes towards the importance of families in nursing care (N = 109) using independent t-tests.

Outcomes	Undergraduate nursing students (n = 64)				Graduate nursing students (n = 45)				t-Value	p-Value
	n	Mean	SD	df	n	Mean	SD	df
Illness beliefs	62	23.1	3.03	104	44	24.5	2.64	104	−2.499	0.014
FINC-NA Total scale	59	95.6	11.10	96	39	101.6	16.13	96	−2.163	0.033
Family as a resource in nursing care (Fam-RNC)	63	39.7	4.85	103	42	39.9	6.64	103	−0.163	0.871
Family as a conversational partner (Fam-CP)	60	29.0	3.67	65.61	43	31.1	5.81	65.61	−2.124	0.037
Family as a burden (Fam-B)	63	12.9	3.06	105	44	15.3	2.66	105	−4.092	0.000
Family as its own resource (Fam-OR)	63	14.2	2.43	104	43	15.6	3.27	104	−2.582	0.011

n varies because of missing data.

Undergraduate nursing students who were working in caregiving during their studies reported a significantly higher perception of the family as a resource in nursing care than undergraduate nursing students who were not working in caregiving during their studies (Fam-RNC) (p < 0.05). This finding indicates that the undergraduate nursing students who were working during their academic studies had more positive attitudes towards family members and the value of their presence in nursing care than the undergraduate nursing students who were not working in caregiving during their academic studies. Graduate nursing students, on the other hand, who were working in caregiving during their studies, reported significantly higher perceptions of their attitudes towards the importance of families in nursing care (FINC-NA total scale) when compared to the graduate students who were not working in caregiving during their studies (p < 0.05). The graduate students who were working in caregiving during their studies also reported significantly higher perception of the family as a conversational partner (Fam-CP) than the graduate students who were not working in caregiving during their studies (p < 0.05). In addition, the graduate students who were working in caregiving during their academic studies also reported a significantly higher percentage on the subscale of perceiving the family as its own resource when compared to the graduate students who were not working in caregiving during their studies (Fam-OR) (p < 0.05) (Table 3 ).

Table 3

Comparison of undergraduate (n = 64) and graduate nursing students (n = 45) illness beliefs and attitudes towards the importance of families in nursing care (N = 109) using independent t-tests.

Outcomes	Undergraduate nursing students (n = 64)				Graduate nursing students (n = 45)				t-Value	p-Value
	n	Mean	SD	df	n	Mean	SD	df
FINC-NA Total scale
Working in caregiving during studies					32	104	12.79	37
Not working in caregiving during studies					7	90.4	25.00	37	−2.111	0.042
Family as a conversational partner (Fam-CP)
Working in caregiving during studies					35	32.1	5.18	40
Not working in caregiving during studies					7	26.0	6.88	40	−2.687	0.010
Family as a resource in nursing care (Fam-RNC)
Working in caregiving during studies	43	40.4	4.19	51
Not working in caregiving during studies	10	36.1	6.23	51					−2.636	0.011
Family as its own resource (Fam-OR)
Working in caregiving during studies					35	16.1	2.52	40
Not working in caregiving during studies					7	13.3	5.62	40	−2.103	0.042

n varies because of missing data.

Discussion

Findings on the difference in illness beliefs between the undergraduate and the graduate nursing students is interesting, where the graduate students were found to report more confidence or reassurance regarding their knowledge on the cause of an illness; their knowledge on how much control they believed their patients and family members had on an illness/health care problem or how much control the illness had on the patients and their families; and their knowledge on who suffered the most in the family and what had been the most helpful of what health care professionals had offered, to help the patients and their families to handle/deal with suffering because of an illness. This finding is new and has not been reported previously in the literature but emphasizes how complex family nursing is and how much training is needed before nursing students can feel confidence in offering families health care services. On the other hand, even though the graduate students reported higher illness beliefs than undergraduate students, the undergraduate students reported a reasonably high score on the illness beliefs scale. These results are in agreement with findings from Saveman et al. (2005), who found that nursing students in Sweden held facilitative beliefs towards meeting families in health care, although they had no specific family nursing education (Saveman et al., 2005). These findings are also in agreement with Meiers et al. (2018), who found that focusing on family nursing throughout an undergraduate nursing education was appropriate, feasible and crucial for advancing family nursing practice. Furthermore, these findings are in line with findings from Gutiérrez-Alemán et al. (2021), who evaluated the effectiveness of educational programs in clinical health care settings when developing family nursing knowledge skills and attitudes in a systematic review of 14 studies and found that clinical competence in family nursing was explained by the nurse's knowledge, skills, and attitudes for family nursing practice. There is a need nevertheless to move towards best educational practices for competency in family nursing both within educational settings, such as within universities, as well as within hospital training educational programs. In an undergraduate program within a university setting, family nursing practice skills can be enhanced in a BSc nursing program by introducing to the students in the 1st and the 2nd year the short therapeutic conversation interventions for families, so undergraduate students can build a capacity over the four years of their BSc nursing education, in the development of their family nursing practice skills, rather than only focusing in their junior years on conceptual knowledge in family-centered nursing care.

The findings from this study regarding a less positive attitude towards involving families in nursing care among undergraduate nursing students when compared to graduate students are nevertheless somewhat surprising because of the emphasize on family nursing competence in our undergraduate curriculum at the 3rd and the 4th year. However, because of the lack of research on nursing students' attitudes and beliefs towards involving families in nursing care at the time of the COVID-19 pandemic, little is known about nursing students' beliefs and attitudes towards family nursing at this time or about how to offer skilled family nursing practice. We need nevertheless, to put even stronger emphasize on the importance of family centered care in our curriculum to facilitate further family nursing practice among our undergraduate nursing students. Graduate nursing students on the other hand, who are more experienced in clinical practice, and may in addition, have the experience of having a family member with serious illness, might be more likely to value the care of the family and to know the importance of involving families in health care, than inexperienced nursing students.

However, the mean of the illness beliefs in this study among the undergraduate nursing students towards the importance of families in nursing care was slightly over medium high, which is similar to the finding from an international study by Cranley et al. (2021) on clinical nurses in Hong Kong. In that study, the clinical nurses in Hong Kong reported a less positive attitude towards family involvement in nursing care than nurses in Canada and Sweden (Cranley et al., 2021). Still, the graduate nurses in this study reported a similar attitude towards involving families in their nursing care as their colleagues did in Ontario in Canada. We are though experiencing conflicting results, in the international literature, regarding the competency among practicing clinical nurses as well as among nursing students regarding their attitude and knowledge towards practicing and offering family system care. In a study by nursing students in Saudi Arabia, Alabdulaziz and Cruz (2020) found that nursing students reported modest perceptions of family-centered care.

Furthermore, the graduate nursing students in this study also reported higher perception of the family as a conversational partner, as well as of the family as its own resource, and reported significantly less perception of the family as a burden in caregiving, such as less negative perception of the presence of family members to be a burden and of not having the time to take care of families, when compared to the undergraduate students. Interestingly, the graduate students who were working in caregiving during their university studies were found to report a higher positive attitude towards family care as well as perceiving families as conversational partners and to perceive the family as its own resource when compared to the graduate students who were not working in caregiving during their studies. Additionally, undergraduate students who were working in caregiving during their studies reported a higher perception of perceiving the family as a resource in nursing care. This finding has not been reported previously and sheds a new light on the richness of clinical experiences during a formal university education, where nursing students at both the undergraduate and the graduate levels are experiencing benefits regarding applying family nursing skills to the clinic through their clinical practices in health care services. These findings are in agreement with Wright and Bell (2021), who emphasize the importance of nurses to enable family members to bring forth their more facilitating beliefs, and they're more loving and compassionate beliefs about one another. Furthermore, according to Wright and Bell, through therapeutic questions, the nurse is creating a particular reality of goodness and curious compassion among family members that is more likely to enable healing. Wright and Bell additionally, put strong emphasis on the kind of a person the nurse can become and can offer healing through therapeutic conversations and that they can a) offer kindness and compassion/concern in therapeutic relationships, b) facilitate change, c) take a relational stance, d) coevolve therapeutic conversations with family members, e) invite reflection, f) not become invested in a particular outcome, and g) be willing to change their own beliefs (Wright and Bell, 2021). Through a strong theoretical and application focus in family nursing education at both the undergraduate and graduate levels, nursing students can integrate research and theory and identify ways to improve the care of families in clinical settings, even at challenging times, such as at the time of the first wave of the COVID-19 pandemic, by building communication skills and confidence in interacting with families in everyday practice.

Study limitations

Few participants and low response rate (18 %) is a limitation, but due to COVID-19 and having the University being locked down, hindered face-to-face introduction of the study to the students. Towards the end of the semester and during the time of the final spring exams, few students are in general watching out for their e-mails from the Faculty of Nursing. Therefore genralizability is limited. Further research is needed using a bigger sample sizes.

Conclusion

At the time of the COVID-19 pandemic, compassion for family nursing has increased among nursing educators, especially since families have been denied visitation or have received restricted visiting hours to their family members at hospitals or at elderly homes. In this study, which was conducted during the first wave of the COVID-19 pandemic, graduate nursing and midwifery students were found to report more confidence and reassurance in their illness beliefs and higher positive attitudes towards the importance of family care than undergraduate students. Nevertheless, the undergraduate nursing students reported reasonable confidence in their illness beliefs. Nursing educators may need at the time of the COVID-19 pandemic to further boost their teaching strategies (especially among undergraduate nursing students) to enhance and/or maintain positive attitudes towards family nursing practice.

CRediT authorship contribution statement

The study was designed by EKS. EKS and GBT analyzed the data. EKS wrote the manuscript. HH and AOS participated in the data collection and critically reviewed the final version of the manuscript.

Declaration of competing interest

The authors have nothing to declare regarding this study (e.g., financial interests or personal relationships) that could have had an impact on the presentation of the manuscript.