Factors Associated With the Perception of Family Nursing Practice Among Mental Health Nurses in Taiwan

Abstract

The aim of this study was to examine factors that influenced the perceptions of mental health nurses about involving families in their nursing practice. A sample of 175 Taiwanese mental health nurses who are employed in both inpatient and community settings completed structured questionnaires designed to measure empathy, attitudes about involving families in care, and perceptions of family nursing practice. Data were analyzed using descriptive statistics, Pearson’s product-moment correlation, t test, one-way ANOVA, and a hierarchical multiple regression analysis. Positive perceptions of family nursing practice were correlated with more years of clinical experience in mental health, empathy, supportive attitudes toward the importance of family nursing care, and personal experiences with family members with serious illness in need of professional care. These findings may assist in the development of effective educational programs designed to help nurses integrate family nursing knowledge and skills in the care of patients and families experiencing mental illness.

Keywords

family nursing practice attitudes toward family importance in mental health nursing care empathy nurses mental health nurses Taiwan

Nurses in the health care delivery system encounter family members of patients on a daily basis. In Taiwan, families often bear major responsibilities in providing care for their relatives with mental disorders (Hsiao & Tsai, 2014; Hsiao & Van Riper, 2009; Huang et al., 2012) and have ongoing relationships with health care providers (Ewertzon, Andershed, Svensson, & Lützén, 2011; Pharaoh, Mari, Rathbone, & Wong, 2010; Schröder, Larsson, & Ahlström, 2007). As emphasized by the International Council of Nurses (ICN; 2008), mental health nursing practice should promote the optimal care for both patients and their families. Mental health nurses may be unaware of the pivotal roles that family members play in the patient’s recovery process and uncertain about how to establish and maintain partnerships with families across the continuum of mental health care (Blomqvist & Ziegert, 2011; Sjöblom, Pejlert, & Asplund, 2005; Weimand, Sällström, Hall-Lord, & Hedelin, 2013). Given the nature of family caregiving in mental illness, more attention needs to focus on gaining a greater understanding of mental health nurses’ perceptions about involving families in their nursing practice as well as the factors that shape mental health nurses’ perceptions of practicing family nursing.

Background

Nurses as a group of mental health care professionals are accountable for the majority of direct care offered to patients suffering from mental illness. The trend of deinstitutionalization, along with shortened hospitalization and increased community-based mental health care, has not only affected the needs of both patients and their families but also placed tremendous demands on the delivery of mental health care services (Chan, 2011; Gavois, Paulsson, & Fridlund, 2006; Schröder et al., 2007). In the context of an evolving mental health care system, it is vital for mental health nurses to acknowledge the importance of both individuals and families who are experiencing mental illness and collaborate simultaneously with individuals and their families in recovery-oriented nursing practice. Family-centered care (FCC) is a holistic care approach that focuses on meeting the needs and concerns of individual patient and the family as a whole (Coyne, O’Neill, Murphy, Costello, & O’Shea, 2011; Foster, Whitehead, & Maybee, 2010). In contrast to patient-centered care, family nursing recognizes the importance of family support in the care of individuals with mental disorders and collaboration with family members (Benzein, Johansson, Årestedt, & Saveman, 2008; Wright & Leahey, 2013).

Lack of family care in mental health practice is a multifaceted problem. A Cochrane systematic review examined the effectiveness of family psychosocial interventions for individuals with schizophrenia and found that family participation in mental health care has the potential to reduce relapse rates and enhance patient recovery (e.g., through increased medication compliance; Pharaoh et al., 2010). Nevertheless, nurses in mental health care often encounter competing demands between caring for individual patients and caring for family members of patients who often require support in their own right. Nurses often experience conflicts or dilemmas concerning support of families due to the absence of adequate knowledge and skills of family-centered approaches (Blomqvist & Ziegert 2011; Simpson, Yeung, Kwan, & Wah, 2006; Sjöblom et al., 2005), lack of available time (Goodwin & Happell, 2007b; Sjöblom et al., 2005), and lack of ongoing contact and attention to family needs (Goodwin & Happell, 2006; Sjöblom et al., 2005). Additional factors that limit nurses’ involvement with families include the lack of professional autonomy, coaching, and organizational support (Blomqvist & Ziegert, 2011); respect and concern for patient confidentiality (Goodwin & Happell, 2006; Weimand et al., 2013); and even the patient’s refusal to involve his or her family in the caring process (Kim & Salyers, 2008). Nurses with a focus on task-oriented care may perceive the presence of family members as a burden although they acknowledge family needs in mental health care services (Sjöblom et al., 2005; Weimand et al., 2013). These dilemmas often place nurses in a double-bind position between patients and their family members in the provision of mental health care (Sjöblom et al., 2005).

Empathy has been identified in the literature as a variable that influences nursing care. Yet limited attention has been paid to the effects of empathy on nursing practice that involves families in mental health care. Empathy is characterized as recognition of individual perspectives that involves an expression of empathic concern by means of communicating an understanding attuned to a person’s experiences and feelings (Hojat, 2007; Williams & Stickley, 2010). A Swedish study found that open and clear communication facilitated nurses’ understandings of the needs of patients and their families that served as a frame to direct their active approaches toward establishing a trustful and supportive relationship with families (Sjöblom et al., 2005). In psychiatric units, nurses often interact with their patients’ family members when providing care (Goodwin & Happell, 2006, 2007a; Sjöblom et al., 2005). However, mental health nurses often prioritize patients’ needs and neglect the importance of families in patients’ lives. As a result, the value of the family in a therapeutic nurse–family relationship (NFR) in mental health care services is rarely acknowledged (Simpson et al., 2006; Sjöblom et al., 2005; Weimand et al., 2013). Such information about the virtue of empathy in family nursing practice is valuable to alleviate the disequilibrium of families and improve optimal care for persons with mental illness as well.

Surveys of nurses across several health care settings have revealed that nurses who are female (Benzein et al., 2008), are more experienced (Benzein et al., 2008; Santiago, Lazar, Jiang & Burns, 2014; Sveinbjarnardottir, Svavardottir, & Saveman, 2011), and have previous experience with their own ill relatives (Benzein et al., 2008) express more supportive attitudes toward involving families as well as perceive greater positive value of family nursing practice. In addition, nurses who regard families as experts and partners of the health care team tend to deliver family nursing practice that acknowledges family members’ needs for support (Gavois et al., 2006; Mitchell & Chaboyer, 2010), engage in conversation with families (Benzein et al., 2008; Mitchell & Chaboyer, 2010; Sjöblom et al., 2005), and initiate a trustful NFR (Austin et al., 2009; Benzein et al., 2008; Simpson et al., 2006). Furthermore, nurses with education about how to be helpful to families demonstrate positive appraisal of family nursing practice in areas such as confidence, satisfaction, knowledge, skills, and comfort in working with families, and show competence in embracing families as partners in nursing care (Simpson et al., 2006; Svavarsdottir et al., 2014).

Most of the existing research about how nurses involve families in nursing practice has adopted qualitative approaches to explore family members’ and health care providers’ perspectives on family-centered practices in pediatric (Coyne et al., 2011; Foster et al., 2010), psychiatric (Goodwin & Happell, 2007a, 2007b; Schröder et al., 2007), and intensive care units (Cypress, 2012; Mitchell & Chaboyer, 2010) in Western countries. Quantitative studies have examined the implementation of Family Systems Nursing (FSN) in various health care settings (Svavardottir, Tryggvadottir, & Sigurdardottir, 2012; Sveinbjarnardottir et al., 2011; Sveinbjarnardottir, Svavardottir, & Wright, 2013) and nursing education (Lindh et al., 2013). Nevertheless, less research exists on the appraisal of family nursing practice by Asian nurses and the reciprocal relationship between families and Asian mental health care personnel, particularly nurses.

To date, the psychiatric mental health nursing (PMHN) curriculum in Taiwanese nursing education has been primarily adapted from the traditional medical model with an emphasis on patient-centered care (Lee, Chen, & Chiang, 2013). In Chinese culture, moreover, the conservative nature and avoidance of family “losing face” may prevent nurses from addressing sensitive mental health matters (e.g., living with mental illness) and engaging with families as collaborative partners in treatment decisions by the interdisciplinary team. Traditional nursing practice in Taiwan has primarily addressed the unique needs of individual patients with only tangential value of collaboration between family members and health care providers. Little attention has been paid to family nursing activities in mental health care facilities. Incorporating a family-oriented philosophy into nursing practice in Taiwan is relatively new (Lee et al., 2013).

Given the importance of interpersonal harmony in traditional family-oriented Taiwanese society, families not only face a lifetime of caregiving demands but also assume the shame and stigma attached to mental illness. As noted, mental illness is a family affair that affects not only patients but also their families who were often ill-equipped to provide continuous support to their ill relatives (Chan, 2011; Chien & Norman, 2009). Without adequate support and resources, relatives of persons with mental illness are likely to become exhausted and in turn, compromise the quality of caregiving delivered to their ill family member.

Families may be regarded as a considerable resource and a collaborative partner, both to patients and health care providers (Sjöblom et al., 2005; Weimand et al., 2013). For mental health care to be holistic, mental health nurses should expand their roles to work with the family as a unit of nursing care, especially those who have assumed a major role in the care of persons suffering from mental illness. Nurses, the largest group of mental health care professionals, play a vital role in the improved quality of nursing care provided they have contact with, listen to, advocate for, and collaborate with patients and their relatives. As a cornerstone of family health in PMHN, understanding the correlates of mental health nurses’ perception of family nursing practice is of particular importance to provide direction for further efforts in supporting family adaptation and enhancing the patients’ recovery as well. The aim of this study was to examine the factors associated with mental health nurses’ perceptions of family nursing practice.

Method

Design

A cross-sectional, correlational design was chosen for this study.

Sample and Setting

A convenience sample of 175 nurses was recruited from acute psychiatric inpatient units, psychiatric rehabilitation units, and outpatient clinics or community psychiatric rehabilitation centers in Taiwan. Inclusion criteria for the sample were mental health nurses who were (a) aged 20 or older, (b) registered nurses (RNs), (c) working in psychiatric facilities for at least 1 year, (d) Chinese- or Taiwanese-speaking, and (e) free from mental illnesses. Of the 206 questionnaires distributed, 175 completed questionnaires were returned, for a response rate of 84.95 %. Sample size estimates were based on a regression analysis to achieve a power of .80 with a medium effect size of .15 and alpha = .05 (Cohen, 1992).

Procedures

Permission to carry out this study was granted by ethics committees at three hospitals. Because community mental health centers do not have Institutional Review Boards, the authors obtained permission from supervisors at each study setting prior to executing this study. The principal investigator explained the purpose of this study to potential participants, discussed and answered concerns, and invited them to participate. Participants were informed about confidentiality assurance and voluntary participation. Mental health nurses who expressed an interest in participation were given a package, including an information sheet, consent form, self-report questionnaires, and return envelope. Before initiating this study, the trained research assistants (RAs) obtained written consent forms from participants. Participants were instructed to return the completed surveys in sealed envelopes. The trained RAs collected the sealed envelopes on a daily basis, and participants who returned questionnaires were given a small gift.

To estimate the feasibility of a proposed study and participants’ understanding of questionnaires, all measures were piloted on a convenience sample of 10 mental health nurses. A pilot test revealed that each item of measures was clear and straightforward to mental health nurses and took approximately 10 to 15 min to complete. Participants in the pilot study were excluded from the main analysis.

Measures

Demographic characteristics

Demographic information sheets included questions related to age, gender, workplace, education, years of clinical experiences as an RN, and personal experiences with family members with serious illness in need of professional care.

Empathy

Empathy was assessed using the Jefferson Scale of Empathy–Health Profession version (JSE-HP version; Hojat et al., 2002), which detects health care providers’ empathic reactions to the patient-care circumstances with respect to perspective taking, compassionate care, and standing in the patient’s shoes. It consists of 20 items with a 7-point Likert-type scale (1 = strongly disagree, 7 = strongly agree). Ten items are reverse scored. Possible scores range from 20 to 140 with higher scores demonstrating greater degrees of empathic orientation. In previous studies, Cronbach alphas were .81 for physicians (Hojat et al., 2002) and .85 for the nurse practitioners (Hojat, Fields, & Gonnella, 2003). The JSE-HP version was translated from English to Chinese following the guidelines for translation and cultural adaption of psychometric instruments (Wild et al., 2005). The content validity index (CVI) of JSE-HP version was 0.91. In this study, Cronbach alpha was .90.

Attitudes toward the family importance in nursing care

Nurses’ attitudes regarding the importance of families were measured by the Families’ Importance in Nursing Care–Nurses’ Attitudes (FINC-NA; Benzein et al., 2008; Saveman, Benzein, Engström, & Årestedt, 2011). The FINC-NA instrument is composed of 26 items. Each item is scored on a 5-point scale ranging from totally disagree (1) to totally agree (5) with possible scores ranging from 26 to 130. Higher scores indicate more supportive attitudes by nurses toward families. The items are divided into four subscales: (a) Family as a Resource in Nursing Care (Fam-RNC), (b) Family as a Conversational Partner (Fam-CP), (c) Family as a Burden (Fam-B), and (d) Family as Its Own Resource (Fam-OR). The reliabilities for the overall scale and Fam-RNC, Fam-CP, Fam-B, and Fam-OR were .92, .87, .83, .73, and .79, respectively (Saveman et al., 2011). The FINC-NA was translated into Chinese according to the principles of translation proposed by Wild et al. (2005) and tested with the CVI of .89. In this study, Cronbach’s alphas for the overall score were .91 and .76 to .86 for the subscales.

Perception of family nursing practice

The perception of family nursing practice by nurses was measured using the 10-item Family Nursing Practice Scale (FNPS) of Chinese version (Simpson & Tarrant, 2006). Total scores are calculated as the mean of all item scores, with scores ranging from 1 (high) to 5 (low). Higher scores represent a lower perception of family nursing practice. The items are divided into two subscales: (a) Practice Appraisal (PA) and (b) nurse–family relationship (NFR). Cronbach’s alphas of the total scale, PA, and NFR subscales in a sample of mental health nurses in Hong Kong (HK) were .84, .85, and .73, respectively. Test–retest reliabilities of the total scale, PA, and NFR subscales were .92, .88, and .87, respectively. As Simpson and Tarrant (2006) mentioned, both English and Chinese versions of the FNPS were developed and distributed to the participants in Hong Kong so that participants could select either Chinese or English version based on their preference. Cronbach’s alphas of the total scale, PA, and NFR subscales for the present sample were .92, .91, and .85, respectively.

Data Analysis

Data were analyzed using the SPSS for Windows (Version 17.0, SPSS Inc., Chicago, Illinois). Descriptive statistics of mental health nurses’ demographic characteristics and study variables were calculated. Pearson’s product-moment correlations were computed to examine the correlations between mental health nurses’ demographic characteristics (i.e., age and years of clinical experiences as a RN), empathy, attitudes toward the family importance in nursing care, and perceptions of family nursing practice. T test or one-way ANOVA was used to examine the differences in mean of perceptions of family nursing practice in relation to mental health nurses’ demographic characteristics (i.e., gender, personal experiences with family members with serious illness in need of professional care, workplace, and education). Scheffe’s post hoc test was conducted for the multi-comparison after one-way ANOVA. A hierarchical multiple regression analysis was applied to identify significant factors that affect the degree of perception of family nursing practice. Model assumptions were checked with a residual analysis. Tolerances and variance inflation factors were applied to detect collinearity. Assumptions of normality were ensured, and collinearity diagnostics indicated no collinearity among variables. A value of p < .05 was considered to achieve a statistical significance.

Results

Mental Health Nurses’ Demographic Characteristics and Study Variables

Demographic characteristics of the mental health nurse participants and study variables are summarized in Table 1. The mean age of the sample of mental health nurses was 32.52 years (SD = 6.45, range = 20-52). Participants in this study were predominantly female (n = 155, 88.6%), had earned a junior college or below degree in nursing (n = 132, 75.4%), and had personal experience with family members with serious illness in need of professional care. More than half of the participants worked in acute psychiatric inpatient units (n = 95, 54.3%), followed by psychiatric rehabilitation units (n = 66, 37.7%) and outpatient clinics or community psychiatric rehabilitation centers (14.8%). Average length of clinical experience as an RN was 7.75 years (SD = 5.22, range = 1-29.58).

Table 1.

Characteristics of Participants and Study Variables (n = 175).

Variables	n (%)	M (SD)	Range
Gender
Male	20 (11.4)
Female	155 (88.6)
Personal experiences with family members with serious illness in need of professional care
No	46 (26.3)
Yes	129 (73.7)
Workplace
Acute psychiatric inpatient units	95 (54.3)
Psychiatric rehabilitation units	66 (37.7)
Outpatient clinics/community	14 (8.0)
psychiatric rehabilitation centers
Education
Junior college or below	132 (75.4)
College	28 (16)
Graduate	15 (8.6)
Age (years)		32.52 (6.45)	20-52
Clinical experiences as an RN (years)		7.75 (5.22)	1-29.58
Empathy		97.23 (13.61)	77-127
Nurses’ attitudes toward the family importance in mental health nursing care		92.54 (10.26)	52-123
Families as a resource in nursing care (Fam-RNC)		37.52 (4.58)	20-50
Family as a conversational partner (Fam-CP)		29.04 (3.63)	16-40
Family as a burden (Fam-B)		11.76 (2.31)	5-20
Family as its own resource (Fam-OR)		14.22 (2.21)	8-20
Perception of the family nursing practice		2.73 (.57)	1-4.2
Practice appraisal (PA)		2.86 (.59)	1.4-4.2
Nurse–family relationship (NFR)		2.61 (.61)	1-4.2

Note. RN = registered nurse.

The means and standard deviations of study variables were as follows: empathy (M = 97.23, SD = 13.61), attitudes toward the family importance in nursing care (M = 92.54, SD = 10.26), and perceptions of family nursing practice (M = 2.73, SD = .57).

Relationships Among Mental Health Nurses’ Demographic Characteristics, Empathy, Attitudes Toward the Family Importance in Nursing Care, and Perceptions of Family Nursing Practice

As indicated in Table 2, perceptions of family nursing practice were significantly and negatively correlated with years of clinical experiences as an RN (r = −.19, p = .014), empathy (r = −.40, p < .001), and attitudes toward the family importance in nursing care (r = −.57, p < .001). That is, more clinical experience and more positive attitudes toward the family importance in care enhanced mental health nurses’ positive perceptions of family nursing. Attitudes toward the family importance in care were positively correlated with years of clinical experience as an RN (r = .18, p = .021) and empathy (r = .30, p < .001).

Table 2.

Correlation Matrix for Nurses’ Characteristics, Empathy, Attitudes Toward the Family Importance in Mental Health Nursing Care, and Perception of Family Nursing Practice (n = 175).

Variables	1.	2.	3.	4.	5.
1. Age	1.00
2. Years of clinical experiences as an RN	.81***	1.00
3. Empathy	.34***	.33***	1.00
4. Nurses’ attitudes toward the family importance in mental health nursing care	.13	.18*	.30***	1.00
5. Perception of family nursing practice	−.11	−.19*	−.40***	−.57***	1.00

Note. RN = registered nurse.

p < .05. ***p < .001.

There was a significant difference in perceptions toward family nursing practice for mental health nurses with personal experience of family members with serious illness in need of professional care (t = 2.29, p = .023) and working at different psychiatric facilities (F = 5.96, p = .003; Table 3). Scheffe’s post hoc test revealed that perceptions of family nursing practice for mental health nurses who worked in acute psychiatric inpatient units were lower than those who worked in psychiatric rehabilitation units, and outpatient clinics or community psychiatric rehabilitation centers.

Table 3.

Perception of Family Nursing Practice by Nurses’ Characteristics (n = 175).

Nurses’ characteristics	Groups	M	SD	t/F	p
Gender				t = −.94	.349
	Male	2.85	.43
	Female	2.72	.58
Personal experiences with family members with serious illness in need of professional care				t = 2.29	.023
	No	2.90	.63
	Yes	2.67	.54
Workplace				F = 5.96	.003
	① Acute psychiatric inpatient units	2.80	.60	①>②>③
	② Psychiatric rehabilitation units	2.74	.50
	③ Outpatient clinics/community psychiatric rehabilitation centers	2.25	.43
Education				F = 2.39	.095
	① Junior college or below	2.77	.56
	② College	2.72	.62
	③ Graduate	2.43	.44

Note. t/F = t value of independent-sample t test or F value of ANOVA; Scheffe’s test for multi-comparison.

Factors Associated With Perceptions of Family Nursing Practice

A hierarchical multiple regression analysis was carried out to examine the associations among empathy, attitudes toward family importance in nursing care, and perceptions toward family nursing practice after controlling for mental health nurses’ characteristics (i.e., years of clinical experiences as an RN, personal experiences with family members with serious illness in need of professional care, and workplace), which had significant relationships with perceptions of family nursing practice. Results of the regression analysis are summarized in Table 4. Model 1 indicates that mental health nurses with personal experiences with family members with serious illness in need of professional care significantly affected perceptions of family nursing practice. Model 2 shows that empathy and attitudes toward the family importance in mental health nursing care were significant factors that influenced perceptions about family nursing practice, which explained 37% of the total variance in perceptions of family nursing practice. These findings revealed that mental health nurses with greater empathy and supportive attitudes toward the family importance in mental health nursing care perceived greater value of family nursing practice in mental health services.

Table 4.

Factors Associated With Perceptions of Family Nursing Practice (n = 175).

Variables	Model 1				Model 2
Variables	b^a [95% CI]	β^b	t	p	b^a [95% CI]	β^b	t	p
Years of clinical experiences as an RN	−.01 [−.03, 0]	−.12	−1.51	.13	0 [−.02, .01]	−.01	−.12	.91
Personal experiences with family members with serious illness in need of professional care	−.2 [−.39, −.01]	−.15	−2.06	.04*	−.03 [−.19, .13]	−.02	−.34	.73
Workplace (acute psychiatric inpatient units)^c	.01 [−.17, .19]	.01	.09	.93	−.1 [−.25, .04]	−.09	−1.39	.17
Workplace (Outpatient clinics/community psychiatric rehabilitation centers)^c	−.25 [−.59, .09]	−.12	−1.46	.15	−.16 [−.45, .12]	−.08	−1.11	.27
Empathy					−.01 [−.02, 0]	−.24	−3.58	<.001***
Attitudes toward the family importance in mental health nursing care					−.03 [−.04, −.02]	−.50	−7.67	<.001***
R ²			.07				.39
Adjusted R²			.05				.37
ΔR²			—				.32
F			3.21*				—
ΔF			—				44.3***

Note. CI = confidence interval; RN = registered nurse; ΔR²: incremental change in R²; ΔF: incremental change in F.

b: unstandardized regression coefficient.

β: standardized regression coefficient.

Referent category: Workplace (psychiatric rehabilitation units).

p < .05. ***p < .001.

Discussion

Our study is the one of the first in Taiwan to assess the factors that influence perceptions of mental health nurses about families and nursing practice with families. This study expands knowledge regarding the correlates of perception of family nursing practice in mental health care reported in previous studies conducted in Western countries (Ewertzon et al., 2011; Schröder et al., 2007) and Asian countries (Kim & Salyers, 2008; Simpson et al., 2006). Findings from this study suggested that nurses’ perceptions should be taken into account to tailor interventions designed to increase nurses’ positive experiences of working with families of people who have mental illness.

The mean scores of the FNPS (M = 2.73) as well as the PA subscale (M = 2.86) and the NFR subscale (M = 2.61) were slightly lower than the scores of mental health nurses in HK found by Simpson and Tarrant (2006). This disparity suggests that family nursing practice in mental health care as perceived by nurses was generally positive and greater than those in HK. This is contrary to the findings that nurses often encountered competing demands or conflicting interests concerning support of family members when caring for the patients (Blomqvist & Ziegert, 2011; Goodwin & Happell, 2007b; Weimand et al., 2013). Such findings may be related to the fact that most mental health nurses in this study had family members with serious illness requiring professional care, thus increasing their awareness of the need for and the value of family participation.

Influenced by Confucian legacies, family hierarchy and harmony are highly valued in Taiwanese society (Chen, 2001). Not only are the roles and responsibilities of individual members clearly identified, but also the values of the individual are subordinate to family interests within the Taiwanese families. However, family nursing in Taiwanese mental health nursing practice is still in an embryonic stage (Li, Rong, Shiau, & Chen, 2014). From our observation, Taiwanese nurses generally adapt family nursing theories and practice models from North America and integrate them into PMHN curriculum in Taiwanese nursing education. Particularly, advanced PMHN includes courses embracing theoretical and practical aspects of comprehensive assessment and psychiatric diagnosis; individual, group, and family psychotherapies; illness prevention and management; and community PMHN (Shiau, Rong, Liu, Wei, & Hsu, 2011). Still, the implementation of family nursing into mental health care practice primarily emphasizes the individuals within the context of family in health promotion and illness management. Accompanying the growth and recognition of the family importance in health care, some nursing schools in Taiwan offer an elective course in family nursing and have even developed a family-centered nursing curriculum with an emphasis on the family as a unit of care across nursing specialties (e.g., maternal–child nursing and PMHN). Typically, family nursing courses at the graduate level include theoretical foundations of family nursing practices (e.g., family social science theories and family therapy theories), family health promotion, family assessment and intervention models (e.g., Calgary Family Assessment and Intervention Models), and family nursing practice in a multidisciplinary practice environment. Taiwan has not yet fully developed family models for nursing practice. Mental illness is a family affair; therefore, the development of family-focused mental health care to help families who face cumulative demands in caregiving circumstance is critically needed (Simpson et al., 2006). In addition, more effort is required to adapt family nursing to Taiwanese culture, especially because stigma about mental illness and a hierarchical health care provider–client relationship are still evident in Taiwanese society.

Coyne and colleagues’ (2011) earlier research in Ireland suggests that most nurses demonstrated knowledge about the core tenets of FCC but were constrained in offering FCC by the absence of hospital and managerial supports. This current study in Taiwan found that nurses in outpatient clinics or community psychiatric rehabilitation centers had more positive perceptions of family nursing than those working in acute psychiatric inpatient units and psychiatric rehabilitation units. This result is similar to findings of Sveinbjarnardottir and colleagues (2011), who found that mental health nurses expressed more positive attitudes working in child and adolescent psychiatric units than those working in acute psychiatric units. As a result of the severity of mental illness and short hospitalization in acute psychiatric inpatient units, it may be that nurses are exposed to heavy workloads and institutional constraints and thus focus primarily on the patient. This limits the possibilities for involving families and impedes family nursing practice in acute psychiatric inpatient units. In view of differing demands depending on the clinical setting of mental health care, more attention needs to be directed toward exploring facilitating and constraining factors in larger systems across different psychiatric specializations and settings.

In the present study, nurses who were experienced and had personal experience with a serious illness in the nurse’s own family that necessitated professional care demonstrated more positive perceptions toward involving families in family nursing practice. These results were similar to those of studies undertaken in Western countries (Santiago et al., 2014; Young et al., 2006). Compared with physicians, nurses, particularly those with more years of nursing practice, were more likely to express more positive attitudes and perceptions in relation to aspects of family participation in multidisciplinary bedside rounds (Santiago et al., 2014). Given the recognition of interdisciplinary collaboration in today’s mental health workplace, further research is required to explore the variation in perceptions of multidisciplinary team members and their determinants toward integrating family-focused care in the clinical environment. Similar to earlier findings about empathy in health care professionals (Hojat et al., 2003; Hojat et al., 2002; Hojat, 2007), female nurses in this study scored higher than male nurses on empathy (t = 2.29, p = .023). As speculated by Hojat (2007), females are often inclined to emphasize interpersonal relationships and express competent understanding of individual emotions; consequently, this may contribute to greater empathic engagement in nursing practice. In addition, a significant relationship was noted between increased positive attitudes toward involving families in patient care and more positive views toward family nursing practice. This could suggest that nurses holding supportive attitudes toward families may be more likely to initiate family nursing practice. Importantly, empathy and attitudes toward involving families in patient care play a critical role in relation to perceptions of mental health nurses about including the family in care. Yet to date, literature on the value of empathy and attitudes toward delivering family-oriented practice is not well known among health care providers in general and among mental health nurses in particular. Other potential factors involving perceptions of family nursing practice should be further investigated, including nurses’ marital status and stigmatized attitudes toward mental illness. It is of interest to expand our knowledge about the influencing factors of family nursing in mental health practice with respect to nurses’ competence in working with families in a way that recognizes the critical roles played by both patients and their families.

Implications for Family Nursing Practice and Education

Mental health nurses are often the first line health care providers who have unique opportunities to provide support to patients and their families experiencing mental illness. To improve the implementation of a family-centered approach in mental health care, efforts should be directed toward helping nurses increase their empathy and supportive attitude about the importance of engaging families in nursing practice as a means of (a) allocation of time for being present with and listening to families to establish a trustful partnership, (b) continuing training programs (e.g., an interactive workshop, online education, or a post-graduate year nursing training) and coaching relevant to knowledge and skills development for therapeutic communication with a recognition of and elaboration on families’ experiences and concerns (Lindh et al., 2013; Sveinbjarnardottir et al., 2011), and (c) supervised practice on reflection with regard to nurses’ attitudes and constraining beliefs about the importance of family presence.

Given that technology-driven practices are highly valued in health care, engendering empathy in nursing education and practice is more crucial than ever (Sheehan, Perrin, Potter, Kazanowski, & Bennett, 2013). Nevertheless, the literature on empathy education and practice is limited (Ward, Cody, Schaal, & Hojat, 2012). In addition to the exposure to role models, educational activities designed to enhance nurses’ empathy across courses within nursing curricula should include aspects of didactic lectures on literature and the art, role-playing in clinical scenarios, reflective writing, guided imagery, supervision of audiotaped or videotaped records of clinical interviews, and patient scenario–based learning (Brunero, Lamont, & Coates, 2010; Sheehan et al., 2013; Ward et al., 2012). Moreover, staff development programs should address the needs of the nurses with different levels of clinical experience and experience working in diverse mental health care settings. Further research on the effectiveness and applicability of family nursing trainings on the quality of nursing care is required.

Limitations

Several limitations to this study exist. First, this was a cross-sectional study in which data were obtained at one point in time; therefore, full understanding of the causality is limited. Families have ongoing relationships not only with individuals experiencing mental illness but also with mental health professionals. Future longitudinal research needs to examine changes in perceptions of family nursing practice and its determinants in psychiatric care. Second, this sample was not randomly selected; therefore, generalizability is limited. Additional research is required to compare perceptions of family nursing practice and its influencing factors among nurses with diverse specialties.

Third, all instruments in this study were self-administered. Biases between self-reflection, perceptions, and actual behaviors may exist. The knowledge translation processes involved in translating family nursing knowledge into clinical practice (Duhamel, 2010; Duhamel, Dupuis, Turcotte, Martinez, & Goudreau, 2015) should be further explored rather than only examining nurses’ perceptions of their family nursing practice. Also, the convenience sample may have included those participants with more positive perceptions of family nursing practice rather than those we did not recruit. Consequently, a selection bias may exist. To bridge the connection among nurses, patients, and families within the context of collaborative partnerships in nursing care, it will be vital to gain points of view from patients, families, and other health care professionals.

Conclusion

As attention to the importance of family participation in all aspects of health care services grows and efforts to improve quality of nursing care are addressed, it is important to understand nurses’ perceptions on family nursing in clinical practice, particularly in mental health care. This study sheds light on the perceptions of mental health nurses in Taiwan about family nursing practice and involving families in nursing care. Empathy and attitudes toward the importance of family in mental health nursing care are key factors that appear to influence positive perceptions of family nursing practice. Given the enormous demands involved in caring for people experiencing mental illness, it is imperative for mental health nurses to be aware of the importance of families in patient care and actively involve families in identifying the families’ needs, realizing their strengths, developing coping strategies, and mobilizing resources to meet their concerns. Professional development programs should be designed for practicing nurses to increase their competence and comfort in collaborating with families of people experiencing mental illness. Knowledge translation research to better understand how to best change nurses’ practice with families is critically needed. Moreover, nursing standards and performance appraisals that reflect the integration of FCC in psychiatric settings would also increase recognition of the accountability of nurses to provide such care.

Footnotes

Acknowledgements

The authors gratefully thank the mental health nurses who participated in this study. Sincere thanks to Ministry of Science and Technology, Taiwan, for funding this study.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by Ministry of Science and Technology, Taiwan (100-2410-H-040-007-MY2).

Author Biographies

Chiu-Yueh Hsiao, PhD, RN, is an Associate Professor at the School of Nursing, College of Medicine, Chung Shan Medical University, Taiwan. Her research and clinical interests focus on examining individual and family adaptation to mental illness and other genetic conditions as well as family-centered nursing care and Family Systems Nursing in mental health care settings. Recent publications include, “Caregiver Burden for Informal Caregivers of Patients With Dementia: A Systematic Review” in International Nursing Review (2015, with H. S. Wu, & C. Y. Chiao); “Factors of Caregiver Burden and Family Functioning Among Taiwanese Family Caregivers Living With Schizophrenia” in Journal of Clinical Nursing (2015, with Y. F. Tsai); and “Caregiver Burden and Satisfaction in Families of Individuals With Schizophrenia” in Nursing Research (2014, with Y. F. Tsai).

Yun-Fang Tsai, PhD, RN, is a Professor and Chair of the School of Nursing, College of Medicine, Chang Gung University, Taiwan. Her specialty is psychiatric mental health nursing, and her research interests are focused on older adults’ care as well as hazardous drinking problems. Recent publications include, “Primary Family Caregivers’ Observations and Perceptions of Their Older Relatives’ Knee Osteoarthritis Pain and Pain Management: A Qualitative Study” in Journal of Advanced Nursing (2015, with K. Y. Hsu, Y. P. Lin, & H. T. Liu); “Triggers of Suicide Ideation and Protective Factors of Actually Executing Suicide Among First Onset Cases in Older Psychiatric Outpatients: A Qualitative Study” in BMC Psychiatry (2014, with S. H, Lee, C. Y. Chen, & L. B. Huang); and “Development and Psychometric Testing of a Chinese-Language Instrument for Assessing Institutionalised Older Males’ Motivations for Living” in Journal of Clinical Nursing (2013, Y. W. Wang, T. K. S. Wong, and Y. C. Ku).

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