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Discrepancies between nurses' current and perceived necessary practices of family-centred care for hospitalised children and their families: A cross-sectional study

  • Patrick G.M.C. Phiri
    Affiliations
    The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Sha Tin, New Territories, Hong Kong Special Administrative Region
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  • Carmen W.H. Chan
    Affiliations
    The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Sha Tin, New Territories, Hong Kong Special Administrative Region
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  • Cho Lee Wong
    Correspondence
    Corresponding author at: Room 824, Esther Lee Building, The Nethersole School of Nursing, Faculty of Medicine, , The Chinese University of Hong Kong, Sha Tin, New Territories, Hong Kong Special Administrative Region.
    Affiliations
    The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Sha Tin, New Territories, Hong Kong Special Administrative Region
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  • Kai Chow Choi
    Affiliations
    The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Sha Tin, New Territories, Hong Kong Special Administrative Region
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  • Marques S.N. Ng
    Affiliations
    The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Sha Tin, New Territories, Hong Kong Special Administrative Region
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      Highlights

      • What is already known about family-centred care (FCC) in developing countries?
      • Nurses and families of hospitalised children support the implementation of FCC.
      • FCC is associated with positive health outcomes if well implemented.
      • There is limited research on scope and factors associated with implementation of FCC What this paper adds?
      • FCC is implemented, accepted, and supported in Malawi but more awareness of its practice is needed among nurses
      • Cultural and religious backgrounds, being separated/widowed are associated with greater implementation of current FCC practices.

      Abstract

      Purpose

      This study investigated (1) the discrepancies between the nurses' current and perceived necessary practices of family-centred care (FCC), and (2) the nurses' demographic characteristics associated with current and perceived necessary practices of FCC for hospitalised children and their families in Malawi.

      Design and methods

      A cross-sectional study involving 444 nurses was conducted. The Family-Centred Care Questionnaire-Revised was used to examine the discrepancies between the nurses' current and perceived necessary practices of FCC. Univariate and multivariate statistical analyses were performed to identify the nurses' demographic characteristics associated with current and perceived necessary practices of FCC.

      Results

      The total mean score of the nurses' current practices of FCC (M = 34.78, SD = 7.06) was significantly lower than that of the nurses' practices of FCC that were perceived as necessary (M = 38.63, SD = 5.60, p < 0.001). The nurses who were over 40 years of age (regression coefficient, β = 9.162, p = 0.014), had a postgraduate qualification (β = 23.314, p < 0.001), were separated or widowed (β = 9.661, p = 0.029), had a Tumbuka cultural background (β = 12.984, p < 0.001), were Seventh-day Adventist members (β = 8.863, p = 0.026), and worked in mission hospitals (β = 16.401, p = 0.021) were more likely to implement current practices of FCC. Conversely, the nurses who were members of the Moslem, Buddhist, or Hindi religious denomination (β = 6.587, p = 0.040), had a Tonga or Ngonde cultural background (β = 6.625, p = 0.046), and were nurse midwife technicians (β = −23.528, p = 0.012) were more likely to implement practices of FCC that they perceived as necessary.

      Conclusion

      Significant differences between the nurses' current and perceived necessary practices of FCC suggested that there were barriers to implementing necessary practices of FCC. The nurses' cultural and religious backgrounds were predictors of current practices of FCC, and this finding could direct the future development and testing of FCC interventions in Malawi.

      Practice implications

      Continued educational activities and research on the factors that contributed to the discrepancies between the nurses' current and perceived necessary practices of FCC and their impact on FCC in Malawi are critical.

      Keywords

      Introduction

      Family-centred care (FCC) is a way of caring for children and their families within health services to ensure that care is planned around the whole family, not just the sick child (
      • Al-Motlaq M.
      • Shields L.
      Family-centered care as a western-centric model in developing countries: Luxury versus necessity.
      ). In FCC, family members are recognised as primary care providers and care recipients (
      • Shields L.
      What is “family-centred care”?.
      ). The Institute for Patient and Family-Centred Care (IPFCC) framework is comprised of four core concepts and nine elements that guide practitioners in the implementation of FCC (
      • Johnson B.H.
      • Jepson E.S.
      • Redburn L.
      Caring for children and families: Guidelines for hospitals.
      ). The four core concepts are respect and dignity, information sharing, family participation in care, and collaboration (
      • Hill C.
      • Knafl C.K.A.
      • Santacroe S.J.
      Family-centered care from the perspective of children cared for in pediatric intensive care units. An integrative review.
      ), while the nine elements (see Table 1) help professionals to operationalise FCC in practice (
      • Mitchell M.L.
      • Coyer F.
      • Kean S.
      • Stone R.
      • Murfield J.
      • Dwan T.
      Patient, family centered care interventions within the adult ICU setting: An integrative review.
      ). Engaging families in the care of their hospitalised children is important because hospitalisation is stressful and families can provide psychological support (
      • Chan C.W.H.
      • Choi K.C.
      • Chien W.T.
      • Cheng K.K.F.
      • Goggins W.
      • So W.K.W.
      • Li C.K.
      Health-related quality-of-life and psychological distress of young adult survivors of childhood cancer in Hong Kong.
      ;
      • Harrison T.
      Family-centered pediatric nursing care: State of the science.
      ;
      • Wong C.L.
      • Ip W.Y.
      • Kwok B.M.C.
      • Choi K.C.
      • Ng B.K.W.
      • Chan C.W.H.
      Effects of therapeutic play on children undergoing cast-removal procedures: A randomised controlled trial.
      ). More developed countries have adopted FCC principles (
      • Abraham M.
      • Moretz J.G.
      Implementing patient- and family-centered care: Part I – Understanding the challenges.
      ) than developing countries such as Malawi, where FCC is in its infancy (
      • Phiri G.M.C.
      • Chan C.W.H.
      • Wong C.L.
      The scope of family-centred care practices, and the facilitators and barriers to implementation of family-centred care for hospitalised children and their families in developing countries: An integrative review.
      ). However, studies have reported the high burden of chronic diseases and the need for FCC in developing countries such as Malawi (
      • Foster M.
      • Whitehead L.
      • Maybee P.
      Parents’ and health professionals’ perceptions of family-centered care for children in a hospital, in developed and developing countries: A review of the literature.
      ;
      • Foster M.
      • Whitehead L.
      • Arabiat D.
      • Frost L.
      Parents' and staff perceptions of parental, needs during a child's hospital admission: An Australian study.
      ; ).
      Table 1Elements of FCC, subscales and subscale items on FCCQ-R.
      Elements of FCC model (
      • Johnson B.H.
      • Jepson E.S.
      • Redburn L.
      Caring for children and families: Guidelines for hospitals.
      )
      Subscales on FCCQ_R (
      • Bruce B.
      Healthcare professionals’ practices and perceptions of family centred care.
      )
      Subscale items
      • 1.
        Recognition that the family is the constant in the child's life, whereas service systems and personnel within those systems fluctuate.
      Family is the constant1–3
      • 2.
        Facilitating parent-professional collaboration at all levels of health care.
      Parent/professional collaboration4–9
      Item 6 was deleted during content validation.
      • 3.
        Recognizing family strengths and individuality and respecting different methods of coping.
      Recognition family individuality10–14
      • 4.
        Sharing unbiased and complete information with parents about their child's care on an ongoing basis in an appropriate and supportive manner.
      Sharing information15–19
      • 5.
        Encouraging parent-to-parent support.
      Parent to parent support20–23
      • 6.
        Understanding and incorporating the developmental needs of infants, children, adolescents, and their families into health care systems.
      Developmental needs24–28
      • 7.
        Implementing appropriate policies and programs that are comprehensive and provide emotional and financial support to meet the needs of families.
      Emotional/financial support29–32
      • 8.
        Ensuring the design of the health care delivery system is flexible, accessible, and responsive to family needs.
      Design of health care system33–39
      • 9.
        Implementation of appropriate policies and programs that are comprehensive and provide emotional support to meet the needs of staff members.
      Emotional support for staff40–45
      a Item 6 was deleted during content validation.
      The has classified developing countries as those with an annual gross national income of less than $200 billion, which includes Malawi. In
      • Matziou V.
      • Manesi V.
      • Vlachoti E.
      • Perdikaris P.
      • Matziou T.
      • Chliara J.I.
      • Mpoutopoulou B.
      Evaluating how pediatric nurses perceive the family-centred model of care and its use in daily practice.
      , developing countries accounted for approximately 67% of the global burden of chronic diseases; in Malawi, nearly 34% of children had long-term illnesses, such as Kaposi's sarcoma, sickle cell disease, or cerebral palsy, that required both hospitalisation and home care (
      • Stanley C.C.
      • Westmoreland K.D.
      • Itimu S.
      • Salima A.
      • der Gronde T.
      • Wasswa P.
      • Mtete I.
      • Butia M.
      • El-Mallawany N.K.
      • Gopal S.
      Quantifying bias in survival estimates resulting from loss to follow-up among children with lymphoma in Malawi.
      ). These long-term illnesses and their home treatments can put pressure on families if they are not supported in the context of FCC (
      • Dix D.B.
      • Klassen A.F.
      • Papsdorf M.
      • Klaassen R.J.
      • Pritchard S.
      • Sung L.
      Factors affecting the delivery of family-centered care in pediatric oncology.
      ). The FCC approach is vital in addressing the needs of families and children (
      • Foster M.
      • Whitehead L.
      • Arabiat D.
      • Frost L.
      Parents' and staff perceptions of parental, needs during a child's hospital admission: An Australian study.
      ). The implementation of FCC principles when working with families and hospitalised children may reduce parents' stress and improve their well-being (
      • Dix D.B.
      • Klassen A.F.
      • Papsdorf M.
      • Klaassen R.J.
      • Pritchard S.
      • Sung L.
      Factors affecting the delivery of family-centered care in pediatric oncology.
      ). However, to date, there is limited evidence regarding the extent and quality of patient- and family-centred care in Malawi (
      • Malawi Ministry of Health
      Quality Management Policy for the Health Sector.
      ). This limited evidence has made it difficult to gauge the current status of FCC empirically.
      A recent review of studies on FCC showed that many failed to use conceptual frameworks and guiding principles, especially studies from developing countries (
      • Phiri G.M.C.
      • Chan C.W.H.
      • Wong C.L.
      The scope of family-centred care practices, and the facilitators and barriers to implementation of family-centred care for hospitalised children and their families in developing countries: An integrative review.
      ). Although a consensus definition of FCC has not been internationally achieved, agreements have been reached on the principles, elements, and models that guide its implementation (
      • Kuo D.Z.
      • Houtrow A.J.
      • Arango P.
      • Kuhlthau A.K.
      • Simmons J.M.
      • Neff J.M.
      Family-centered care: Current applications and future directions in pediatric health care.
      ). To understand how FCC has been practised and perceived among nurses in Malawi, the current study used the IPFCC framework, particularly the nine elements that guide the implementation of FCC in practice (see Table 1;
      • Jolley J.
      • Shields L.
      The evolution of family-centered care.
      ). To achieve this, the study measured the extent to which nurses in Malawi implemented current practices of FCC and practices of FCC that they perceived as necessary, and the Family-Centred Care Questionnaire-Revised (FCCQ-R) (
      • Bruce B.
      Healthcare professionals’ practices and perceptions of family centred care.
      ) was used to collect data on the measures in the domains of current practices and necessary practices of FCC. The current practices domain measures the extent to which nurses or healthcare workers include FCC activities in each element of FCC in their everyday work, and the necessary practices domain measures the extent to which nurses or healthcare workers implement FCC activities in each element of FCC that they perceive as necessary (
      • Bruce B.
      Healthcare professionals’ practices and perceptions of family centred care.
      ; see Supplement 2).
      Discrepancies between the implementation of current and perceived necessary practices of FCC have been associated with some background characteristics of nurses, as reported in previous studies from developed Western and Eastern countries (
      • Alabdulazziz H.
      • Moss C.
      • Copnell B.
      Paediatric nurses' perceptions and practice of family-centred care in Saudi hospitals: A mixed methods study.
      ;
      • Bruce B.
      • Letourneau N.
      • Ritchie J.
      • Larocque S.
      • Dennis C.
      • Elliott M.R.
      A multisite study of health professionals’ perceptions and practices of family-centered care.
      ;
      • Coyne I.
      • Murphy M.
      • Costello T.
      • O'Neill C.
      • Donnellan C.
      A survey of nurses' practices and perceptions of family-centered care in Ireland.
      ;
      • Dall'Oglio I.
      • Mascolo R.
      • Gawronski O.
      • Tiozzo E.
      • Portanova A.
      • Ragni A.
      • Latour J.M.
      A systematic review of instruments for assessing parent satisfaction with family-centered care in neonatal intensive care units.
      ;
      • Foster M.
      • Whitehead L.
      • Arabiat D.
      • Frost L.
      Parents' and staff perceptions of parental, needs during a child's hospital admission: An Australian study.
      ;
      • Matziou V.
      • Manesi V.
      • Vlachoti E.
      • Perdikaris P.
      • Matziou T.
      • Chliara J.I.
      • Mpoutopoulou B.
      Evaluating how pediatric nurses perceive the family-centred model of care and its use in daily practice.
      ). For instance, associations between a greater degree of FCC implementation and nurses' age, gender, years of experience, and number of children have been documented in developed countries (
      • Bruce B.
      • Letourneau N.
      • Ritchie J.
      • Larocque S.
      • Dennis C.
      • Elliott M.R.
      A multisite study of health professionals’ perceptions and practices of family-centered care.
      ;
      • Matziou V.
      • Manesi V.
      • Vlachoti E.
      • Perdikaris P.
      • Matziou T.
      • Chliara J.I.
      • Mpoutopoulou B.
      Evaluating how pediatric nurses perceive the family-centred model of care and its use in daily practice.
      ). In contrast, studies in developing countries that examined current and necessary practices of FCC using the nine elements outlined in the IPFCC framework (
      • Jolley J.
      • Shields L.
      The evolution of family-centered care.
      ) are limited compared with those in Western and developed countries. Studies that use elements of FCC and their evaluative terms are regarded as robust, providing an overall family-centredness of care (
      • Foster M.J.
      • Whitehead L.
      • Maybee P.
      • Cullens V.
      The parents’, hospitalized child’s,and health care providers’ perceptions and experiences of family centered care within a pediatric critical care setting.
      ). For instance, in their review,
      • Foster M.J.
      • Whitehead L.
      • Maybee P.
      • Cullens V.
      The parents’, hospitalized child’s,and health care providers’ perceptions and experiences of family centered care within a pediatric critical care setting.
      critically analysed FCC studies using the nine elements of the IPFCC framework as the criteria for the centredness of FCC and found 59 studies that used some of the nine elements, but only a few were from developed countries. This finding of the disparity of studies that used elements of the IPFCC framework between developed and developing countries indicated a research gap in studies on FCC in developing countries (
      • Phiri G.M.C.
      • Chan C.W.H.
      • Wong C.L.
      The scope of family-centred care practices, and the facilitators and barriers to implementation of family-centred care for hospitalised children and their families in developing countries: An integrative review.
      ).
      Studying FCC from the perspective of the IPFCC framework's nine original elements has become an important research goal that could lead to improved quality of care in children's and young people's nursing (
      • Coyne I.
      • Murphy M.
      • Costello T.
      • O'Neill C.
      • Donnellan C.
      A survey of nurses' practices and perceptions of family-centered care in Ireland.
      ;
      • Dall'Oglio I.
      • Mascolo R.
      • Gawronski O.
      • Tiozzo E.
      • Portanova A.
      • Ragni A.
      • Latour J.M.
      A systematic review of instruments for assessing parent satisfaction with family-centered care in neonatal intensive care units.
      ). Thus, further studies are still warranted to examine the discrepancies between current and perceived necessary practices of FCC for hospitalised children and their families in developing countries such as Malawi. The current study aimed to investigate (1) the discrepancies between the extent to which nurses implement current and perceived necessary practices of FCC, and (2) the nurses' demographics associated with current practices of FCC and practices that nurses perceived as necessary for hospitalised children and their families in Malawi.

      Methods

      Study design and settings

      A cross-sectional study was carried out. Data were collected from nurses who worked in paediatric sections at district, mission, and central hospitals in Malawi. In Malawi, central hospitals are government national or regional referral hospitals that provide specialised tertiary care, while district and mission hospitals provide mainly secondary level non-specialised care. However, mission hospitals are owned by religious groups under the Christian Health Association of Malawi (CHAM) and provide most of their services at a cost. The government provides 60% of healthcare services and CHAM facilities provide nearly 40% of healthcare services in Malawi (
      • Malawi Ministry of Health
      Quality Management Policy for the Health Sector.
      ).

      Participants

      The study targeted full-time nurses between 21 and 60 years of age who worked in a paediatric ward, with at least one year of paediatric experience. Ethical approval was obtained from the National Health Sciences Research Ethics Committee (NHSRC/1906/2353) and the Chinese University of Hong Kong–Survey and Behavioural Research Ethics Committee (SBRE19–1806). Detailed information was given to all eligible participants through an information letter. The participants who agreed to participate signed an informed consent form.

      Sample size

      The sample size was calculated using the power analysis software PASS 14.0 (NCSS, Kaysville, Utah, USA). A sample of at least 387 nurses would provide 80% statistical power to detect an association at the 5% level of significance, with an effect size as small as R2 = 0.02 between socio-demographic factors and current and perceived necessary practices of FCC. Further allowing for a 10% non-completion rate, the study aimed to recruit at least 430 eligible nurses as participants. Finally, a sample of 444 full-time nurses was recruited.

      Measures

      Data were collected from September to November 2019. The researcher and research assistants approached hospital managers and ward in-charges, who in turn introduced them to nurses in their respective wards. Then, the researcher or research assistants approached each nurse individually for a briefing and explained the details of the study to them. Those who were interested in joining the study were invited to sign an informed consent form. Once recruited into the study, the research assistants provided them with the FCCQ-R to complete. The socio-demographic variables collected included age, gender, marital status, education level, professional level, specialisation, ward type, religion, cultural group, years of experience, number of children, and hospital type.
      The FCCQ-R was used to assess how nurses practised and perceived FCC (
      • Bruce B.
      Healthcare professionals’ practices and perceptions of family centred care.
      ;
      • Bruce B.
      • Ritchie J.
      Nurses’ practices and perceptions of family-centered care.
      ). The FCCQ-R was developed in line with the nine key elements of the IPFCC framework, and it asks health professionals to indicate, first, the extent to which each activity is included in their everyday work (i.e., current practices of FCC), and second, the extent to which the activity is necessary in providing FCC (i.e., necessary practices of FCC) (
      • Bruce B.
      • Ritchie J.
      Nurses’ practices and perceptions of family-centered care.
      ; see Supplement 2). The FCCQ-R consists of 45 items among nine subscales and uses a 5-point Likert scale, from 1 (strongly disagree) to 5 (strongly agree). The mean scores of each subscale range from 1 to 5, while the mean scores of the domains of current practices and necessary practices range from 9 to 45. The number of activities in each subscale differ, but a mean score above 3 in each subscale and an average score above 27 for each domain represents considerable current and necessary practices of FCC (
      • Letourneau N.
      • Elliott M.R.
      Pediatric health care professionals’ perceptions and practices of family-centered care.
      ). To guide on how the FCCQ-R's subscales and their representative items in each domain are scored is included in Supplement 3. Higher scores represent wider implementation as well as a high degree of perceived importance of the FCC elements to implement (
      • Bruce B.
      • Letourneau N.
      • Ritchie J.
      • Larocque S.
      • Dennis C.
      • Elliott M.R.
      A multisite study of health professionals’ perceptions and practices of family-centered care.
      ). The FCCQ-R has been validated by the original authors (
      • Bruce B.
      • Ritchie J.
      Nurses’ practices and perceptions of family-centered care.
      ), with internal consistency coefficients of 0.50 to 0.90 (
      • Alabdulazziz H.
      • Moss C.
      • Copnell B.
      Paediatric nurses' perceptions and practice of family-centred care in Saudi hospitals: A mixed methods study.
      ;
      • Bruce B.
      • Letourneau N.
      • Ritchie J.
      • Larocque S.
      • Dennis C.
      • Elliott M.R.
      A multisite study of health professionals’ perceptions and practices of family-centered care.
      ). In this study, the content validity of the FCCQ-R was assessed by 10 paediatric and child health experts in Malawi, and the content validity indices ranged between 0.85 and 0.97, which were satisfactory (
      • Rosner B.
      Fundamentals of statistics.
      ). As Malawi's official language is English, translation of the FCCQ-R was not required. The Cronbach's alpha values of the total current and necessary practices domains were 0.873 and 0.820, respectively. All of the subscale coefficients were greater than 0.700, except for the Family is the constant subscale in the current and necessary practices domains, which were 0.545 and 0.526, respectively. The low scores of the Family is the constant subscale have been reported in previous studies (
      • Alabdulazziz H.
      • Moss C.
      • Copnell B.
      Paediatric nurses' perceptions and practice of family-centred care in Saudi hospitals: A mixed methods study.
      ;
      • Bruce B.
      • Ritchie J.
      Nurses’ practices and perceptions of family-centered care.
      ;
      • Matziou V.
      • Manesi V.
      • Vlachoti E.
      • Perdikaris P.
      • Matziou T.
      • Chliara J.I.
      • Mpoutopoulou B.
      Evaluating how pediatric nurses perceive the family-centred model of care and its use in daily practice.
      ; see Supplementary Table 1).

      Statistical analyses

      The data were analysed using IBM SPSS Version 25. Appropriate descriptive statistics were used to examine the characteristics of the sample. The normality of variables with continuous data was evaluated using skewness statistics and normal probability plots. Paired-samples t-tests were used to compare the means between current practices and necessary practices (
      • Rosner B.
      Fundamentals of statistics.
      ). Multiple regressions were conducted to examine the associations between the nurses' background characteristics and the total scores of each of the subscales in the current and necessary practices domains (
      • Morozova O.
      • Levina O.
      • Uusküla A.
      • Heimer R.
      Comparison of subset selection methods in linear regression in the context of health-related quality of life and substance abuse in Russia.
      ). The categorical variables of the nurses' background characteristics were first recoded to dummy variables before entering them into multiple regression analysis. The categories of the categorical variables that had less than 10 participants were regrouped to avoid the possibility of yielding unreliable estimates in the linear regressions (
      • Morozova O.
      • Levina O.
      • Uusküla A.
      • Heimer R.
      Comparison of subset selection methods in linear regression in the context of health-related quality of life and substance abuse in Russia.
      ). All statistical tests were two-sided, with the level of significance set at 0.05.

      Results

      Socio-demographic characteristics of the sample

      A total of 444 nurses returned the questionnaires for analysis, representing a 100% response rate. The participants' mean age was 31.4 years old (SD = 6.1 years). Among them, 66.4% were women, 55.0% were married, and 56.9% had fewer than four children. Nurses of Tumbuka origin (24.5%) formed the largest single group with respect to cultural background. Most of the participants (55.4%) had a nursing midwifery technician diploma. More than half (58.5%) were nurse midwife technicians (NMTs) and 43.2% worked in general wards (see Table 2).
      Table 2Background characteristics of the participants (N = 444).
      CharacteristicsSubgroupn (%)
      Age (years)21–2592 (20.7)
      26–30144 (32.4)
      31–35106 (23.9)
      36–4066 (14.7)
      >4036 (8.3)
      GenderMale149 (33)
      Female295 (66.4)
      Marital statusSingle149 (33.6)
      Married244 (55)
      Separated/widowed51 (11.4)
      Number of Children0175 (39.4)
      1–4248 (56.9)
      ≥ 521 (4.7)
      Education levelCert. in Nursing21 (4.7)
      Diploma (NM-T)246 (55.4)
      Diploma (RN)61 (13.7)
      Bachelor97 (21.9)
      Postgraduate qualification19 (4.3)
      Religious denominationCatholic82 (18.5)
      CCAP111 (25.0)
      SDA97 (21.9)
      Church of Christ74 (16.7)
      Pentecostals/J. Witness45 (10.2)
      Moslem/Buddha/Hindu35 (7.9)
      Cultural backgroundChewa84 (19.9)
      Tumbuka109 (24.5)
      Yawo84 (18.9)
      Lhomwe85 (19.1)
      Sena/Mang'anja26 (5.9)
      Tonga/Ngonde56 (12.7)
      Professional levelNMT260 (58.6)
      RN184 (41.4)
      SpecialisationNo387 (87.2)
      Yes57 (12.8)
      Ward typeMedical16 (3.6)
      Surgical49 (11.0)
      Nursery151 (34.0)
      NRU/Orthopedic/Oncology37 (8.13)
      General Ward191 (43.0)
      Work experience (years)1–5229 (51.7)
      6–10128 (28.9)
      11–1561 (13.9)
      > 1525 (5.6)
      Hospital typeDistrict142 (32.0)
      Mission124 (27.9)
      Central178 (40.1)
      Data are presented as frequency (percentage)
      CCAP = Church of Central Africa Presbyterian; Diploma NMT = Diploma in Nursing and Midwifery Technician course; Diploma RN=Diploma Registered Nursing course = NMT = Nurse Midwife Technician; NRU = Nutrition Rehabilitation Unit; RN = Registered Nurse; SDA = Seventh Day Adventist; J/Witness = Jehovas' Witness.

      Discrepancies between current and necessary practices of FCC

      The findings revealed that the total mean score of the necessary practices domain (M = 38.63, SD = 5.60) was higher than that of the current practices domain (M = 34.78, SD = 7.06). In the subscales in the current practices domain, Family is the constant was ranked the highest (M = 4.09, SD = 0.67). Conversely, the Recognizing family individuality subscale received the lowest score (M = 3.60, SD = 0.97). In the subscales in the necessary practices domain, the Developmental needs and Design of health care system subscales received the highest scores (M = 4.41, SD = 0.68 and M = 4.41, SD = 0.57, respectively). The Recognizing family individuality subscale received the lowest score (M = 4.21, SD = 0.87). Paired t-tests were conducted to compare the scores of the subscales in the current and necessary practices domains, and statistically significant differences were found in all the subscales (p ≤ 0.001) (see Table 3).
      Table 3Scores of FCCQ_R between current and necessary practice (N = 444).
      Subscales of FCCQ_RCurrent (MSD)Necessary (MSD)t scoresdfP-value #
      • 1.
        Family is constant
      4.09 (0.67)4.37 (0.60)−0.84443<0.001
      • 2.
        Parent-professional collaboration
      3.85 (0.65)4.22 (0.63)0.84443≤0.001
      • 3.
        Recognizing family individuality
      3.60 (0.97)4.21 (0.87)−4.47443<0.001
      • 4.
        Sharing Information
      3.83 (0.92)4.29 (0.59)−3.12443<0.001
      • 5.
        Developmental needs
      3.93 (0.70)4.41 (0.68)−2.48443<0.001
      • 6.
        Parent to parent support
      3.86 (0.77)4.26 (0.60)−2.02443<0.001
      • 7.
        Emotional/financial support
      3.99 (0.71)4.30 (0.56)−3.57443<0.001
      • 8.
        Design of health care
      3.73 (0.82)4.41 (0.57)−3.38443<0.001
      • 9.
        Emotional support for staff
      3.90 (0.85)4.37 (0.55)−2.81443<0.001
      Total FCC score34.78 (7.06)38.63 (5.60)−21.88443<0.001
      Data are presented as mean (standard deviation); # Paired t-test; df = degrees of freedom.

      Predictors of current and necessary practices of FCC based on the nurses' background characteristics

      Multiple regressions were conducted to identify the nurses' specific background characteristics that were associated with current and necessary practices of FCC. Compared with the youngest age group (21 to 25 years old), the nurses over 40 years of age were more likely to implement current practices of FCC (regression coefficient, β = 9.162, p = 0.014), and those aged between 36 and 40 years old were less likely to do so (β = −11.715, p = 0.045). Regarding marital status, compared with those who were single, the nurses who were separated and those who were widowed were more likely to implement current practices of FCC (β = 9.661, p = 0.029), while the nurses who were married were less willing to do so (β = −9.258, p = 0.048).
      The nurses with a postgraduate qualification (β = 23.314, p < 0.001) and the NMTs with a diploma in nursing (β = 8.863, p = 0.025) were more likely to implement current practices of FCC compared with those with other undergraduate certificates in nursing. The nurses who had either a Tumbuka or a Yawo cultural background were more likely to implement current practices of FCC than those who had other cultural backgrounds (β = 2.684, p < 0.001 and β = 8.333, p = 0.035, respectively). Similarly, the nurses who were members of the Seventh-day Adventist religious denomination were more likely to implement current practices of FCC (β = 8.863, p = 0.026) compared with those who were members of other religious denominations. The nurses who worked in central hospitals (β = 8.958, p ≤ 0.001) were more likely to implement current practices of FCC than those who worked in mission hospitals (β = 16.401, p = 0.021), although both significantly embraced current practices of FCC. The nurses in surgical wards were more likely to implement current practices of FCC (β = 8.404, p = 0.006) than those in other wards. On the contrary, nurses who were Tonga or Ngonde were more likely to implement practices of FCC that they perceived as necessary (β = 6.625, p = 0.046) as well as those who were members of the Moslem, Buddhist, or Hindi religious denomination (β = 6.587, p = 0.040). Compared with the NMTs, the registered nurses were less likely to implement practices of FCC that were perceived as necessary (β = −23.528, p = 0.012). Table 4 summarises the findings.
      Table 4Linear regression: predictors of current and necessary FCC practices by subgroups (N = 444).
      CharacteristicsCurrentNecessary
      ΒSEP-valueβSEP-value
      Age (years)
       21–25 (ref)
       26–303.7213.4710.2841.9742.5410.438
       31–35−5.8564.1720.1614.5883.7470.221
       36–40−11.7155.8260.045−0.9893.0540.746
       >409.1623.7030.014−5.7615.1180.261
      Gender
       Male (ref)
       Female4.5942.6640.085−0.9701.9310.616
      Marital status
       Single (ref)
       Married−9.2584.6620.0483.3641.9290.082
       Separated/widowed9.6614.4200.0292.4133.6090.504
      Number of children
       0 (ref)
       1–4−0.9701.9310.1912.3822.0760.252
       ≥ 5−0.9701.9310.5770.9043.6820.806
      Education level
       Cert. in Nursing (ref)
       Diploma (NM-T)8.8633.9370.0254.1223.8770.288
       Diploma (RN)4.5625.0060.363−0.0340.1620.522
       Bachelor−11.5025.6370.0427.3024.1610.080
       #Postgraduate qualification23.3144.676<0.0013.4106.4550.598
      Religious denomination
       Catholic (ref)
       CCAP6.2283.8410.106−1.0322.7960.712
       SDA8.8633.9700.026−3.9012.8820.177
       Church of Christ6.6964.2290.114−2.4693.0800.423
       Pentecostals/J. Witness0.5614.8930.115−1.4253.5640.689
       Moslem/Buddha/Hindu−4.9605.3250.0476.5873.8790.040*
      Cultural background
       Chewa (ref)
       Tumbuka12.6843.714<0.0013.8982.7840.162
       Yawo8.3333.9470.0354.2382.9590.153
       Lhomwe−8.6003.9350.0292.5302.9500.392
       Sena/Mang'anja−5.6395.7400.326−1.1954.3030.781
       Tonga/Ngonde−16.0424.413<0.0016.6253.3080.046
      Professional level
       NMT (ref)
       RN−4.2322.5540.098−23.5289.330.012
      Specialisation
       No (ref)
       Yes−1.2362.7460.653−3.7433.7980.325
      Ward type
       Medical (ref)
       Surgical8.4046.6350.006−3.3444.3790.446
       Nursery−9.9085.9000.094−1.5064.9250.444
       NRU/Ortho/Oncology−0.8943.6890.017−8.0095.3500.135
       General ward−10.8205.0060.0316.7813.7160.069
      Work Experience (years)
       1–5 (ref)
       6–10−3.4432.9160.238−3.3472.1050.113
       11–15−3.4963.8230.361−0.5402.7600.845
       >15−5.2086.1960.4010.8174.4730.855
      Hospital type
       District (ref)
       Mission16.4017.0880.021−1.3682.7770.623
       Central8.9582.781≤0.001−1.2052.0320.554
       R20.3120.211
      #Postgraduate Diploma. β: Regression coefficient; SE: Standard Error of the regression coefficient.
      CCAP = Church of Central Africa Presbyterian; Diploma NM-T = Diploma in Nursing and Midwifery-Technician course; Diploma RN=Diploma Registered Nursing course = NMT = Nurse Midwife Technician; NRU = Nutrition Rehabilitation Unit; Ortho = Orthopedic Ward; RN = Registered Nurse; SDA = Seventh Day Adventist; J/Witness = Jehovas' Witness.

      Discussion

      This study investigated the discrepancies between the nurses' perceptions of current and necessary practices of FCC for hospitalised children and their families based on the nine elements of the IPFCC framework (
      • Johnson B.H.
      • Jepson E.S.
      • Redburn L.
      Caring for children and families: Guidelines for hospitals.
      ). To the best of the researchers' knowledge, this is the first study to use the original elements of the framework and a validated data collection tool to study FCC in developing countries. The findings demonstrated that FCC was practised in Malawi and that these practices were highly valued by the nurses. These findings supported the values, beliefs, and principles of the IPFCC framework, which highlights that for organisations or nurses to claim that they implement FCC in their everyday care practices, all the components of the framework must be reflected in their practices (
      • Hill C.
      • Knafl C.K.A.
      • Santacroe S.J.
      Family-centered care from the perspective of children cared for in pediatric intensive care units. An integrative review.
      ). In addition, FCC is about providing respectful, culturally responsive care that meets the needs and beliefs of families and their sick children from diverse backgrounds (
      • Crocker E.
      • Webster P.D.
      • Johnson B.H.
      Developing patient- and family centered vision, Mission, and philosophy of care statements.
      ). As such, the findings from the current study further supported the suitability of implementing the IPFCC framework's elements in everyday care practices of FCC.
      The results demonstrated that there were discrepancies between current and perceived necessary practices of FCC in the current settings. However, the total mean scores of both the current and necessary practices domains were above the neutral level score of 3 (
      • Bruce B.
      • Ritchie J.
      Nurses’ practices and perceptions of family-centered care.
      ). This finding thus suggested that FCC was widely practised, accepted, and supported by the nurses in the current settings (
      • Dall'Oglio I.
      • Mascolo R.
      • Gawronski O.
      • Tiozzo E.
      • Portanova A.
      • Ragni A.
      • Latour J.M.
      A systematic review of instruments for assessing parent satisfaction with family-centered care in neonatal intensive care units.
      ). Indeed, compared with previous studies, the implementation of FCC as a model of care has improved as indicated by the increase in the scores of the current practices of FCC (
      • Alabdulazziz H.
      • Moss C.
      • Copnell B.
      Paediatric nurses' perceptions and practice of family-centred care in Saudi hospitals: A mixed methods study.
      ;
      • Bruce B.
      • Ritchie J.
      Nurses’ practices and perceptions of family-centered care.
      ;
      • Coyne I.
      • Murphy M.
      • Costello T.
      • O'Neill C.
      • Donnellan C.
      A survey of nurses' practices and perceptions of family-centered care in Ireland.
      ).
      The Recognizing family individuality subscale earned the highest ranking in the necessary practices domain in previous studies (
      • Bruce B.
      • Ritchie J.
      Nurses’ practices and perceptions of family-centered care.
      ;
      • Coyne I.
      • Murphy M.
      • Costello T.
      • O'Neill C.
      • Donnellan C.
      A survey of nurses' practices and perceptions of family-centered care in Ireland.
      ), but it was ranked lower in the current study (see Table 3). This finding suggested that the nurses in the current study did not find it necessary to consider the needs of individual families (
      • Letourneau N.
      • Elliott M.R.
      Pediatric health care professionals’ perceptions and practices of family-centered care.
      ). The lack of recognizing a family's individual needs is contrary to the values of FCC (
      • Sodomka P.
      Engaging patients and families: A high leverage tool for health care leaders.
      ). In contrast, the Parent-to-parent support, Emotional and financial support for families, and Parent and professional collaboration subscales in the necessary practices domain were ranked higher in the current study compared with the findings of
      • Alabdulazziz H.
      • Moss C.
      • Copnell B.
      Paediatric nurses' perceptions and practice of family-centred care in Saudi hospitals: A mixed methods study.
      ,
      • Dall'Oglio I.
      • Mascolo R.
      • Gawronski O.
      • Tiozzo E.
      • Portanova A.
      • Ragni A.
      • Latour J.M.
      A systematic review of instruments for assessing parent satisfaction with family-centered care in neonatal intensive care units.
      , and
      • Murphy M.
      • Fealy G.
      Practices and perception of family-centred care among children’s nurses in Ireland.
      . Furthermore, in previous studies, the Design of health care system subscale was the lowest-ranked subscale among the subscales in the current and necessary practices domains (
      • Bruce B.
      • Letourneau N.
      • Ritchie J.
      • Larocque S.
      • Dennis C.
      • Elliott M.R.
      A multisite study of health professionals’ perceptions and practices of family-centered care.
      ;
      • Murphy M.
      • Fealy G.
      Practices and perception of family-centred care among children’s nurses in Ireland.
      ). However, the findings of this study showed that this element was widely practised and valued by the nurses. These differences between the current and previous studies suggested that countries implemented and valued FCC differently (
      • Feeg V.
      • Paraszczuk A.
      • Çavuşoğlu H.
      • Shields L.
      • Pars H.
      • Al Mamun A.
      How is family centered care perceived by healthcare providers from different countries? An international comparison study.
      ).
      • Dall'Oglio I.
      • Mascolo R.
      • Gawronski O.
      • Tiozzo E.
      • Portanova A.
      • Ragni A.
      • Latour J.M.
      A systematic review of instruments for assessing parent satisfaction with family-centered care in neonatal intensive care units.
      and
      • Rostami F.
      • Tajuddin S.H.
      • Yaghmai F.
      • Suriani B.I.
      • Binsuandi T.
      The effect of educational intervention on nurses’ attitudes toward the importance of family-centered care in pediatric wards in Iran.
      concluded that healthcare workers' inadequate awareness of FCC was linked to less FCC implementation. Thus, there is a need to increase FCC education and awareness activities among nurses internationally. Moreover, in the current settings, the improvements in the practices and perceptions of FCC activities could be partly attributable to the government's quality assurance policies and support, which emphasise consumer participation in healthcare via exit interviews and Hospital Advisory Committees (
      • Malawi Ministry of Health
      Quality Management Policy for the Health Sector.
      ).
      Similar to previous studies, the current findings demonstrated that the age of the nurses significantly predicted current practices of FCC. This study also found that the nurses over 40 years of age were more likely to implement current practices of FCC than those below the age of 40 (
      • Dall'Oglio I.
      • Mascolo R.
      • Gawronski O.
      • Tiozzo E.
      • Portanova A.
      • Ragni A.
      • Latour J.M.
      A systematic review of instruments for assessing parent satisfaction with family-centered care in neonatal intensive care units.
      ;
      • Letourneau N.
      • Elliott M.R.
      Pediatric health care professionals’ perceptions and practices of family-centered care.
      ).
      • Dall'Oglio I.
      • Mascolo R.
      • Gawronski O.
      • Tiozzo E.
      • Portanova A.
      • Ragni A.
      • Latour J.M.
      A systematic review of instruments for assessing parent satisfaction with family-centered care in neonatal intensive care units.
      and
      • Letourneau N.
      • Elliott M.R.
      Pediatric health care professionals’ perceptions and practices of family-centered care.
      suggested that nurses who were older than 40 years of age were optimistic, had a greater capacity to go beyond formal barriers, and appreciated the core values of FCC.
      Whereas degree-level education has been reported to significantly influence the implementation of FCC (
      • Bruce B.
      • Letourneau N.
      • Ritchie J.
      • Larocque S.
      • Dennis C.
      • Elliott M.R.
      A multisite study of health professionals’ perceptions and practices of family-centered care.
      ;
      • Matziou V.
      • Manesi V.
      • Vlachoti E.
      • Perdikaris P.
      • Matziou T.
      • Chliara J.I.
      • Mpoutopoulou B.
      Evaluating how pediatric nurses perceive the family-centred model of care and its use in daily practice.
      ), the current study demonstrated that the nurses with a postgraduate qualification were more likely to implement current practices of FCC. The contribution of nurses with postgraduate qualifications to FCC implementation has not been well documented previously. However, literature from general nursing practices demonstrated that there was a positive relationship between postgraduate-trained nurses and the extent to which those nurses responded to patients' care, patients' needs, and their ability to deliver advanced nursing care that was holistic and client-centred (
      • Barnhill D.
      • McKillop A.
      • Aspinall C.
      The impact of postgraduate education on registered nurses working in acute care.
      ;
      • Hallinan C.M.
      • Hegarty K.L.
      Advanced training for primary care and general practice nurses: Enablers and outcomes of postgraduate education.
      ;
      • Wilkinson J.
      • Carryer J.
      • Budge C.
      Impact of postgraduate education on advanced practice nurse activity-a national survey.
      ). Current findings further demonstrated that the NMTs with a diploma in nursing and midwifery also implemented current practices of FCC to a greater extent compared with those with a bachelor's degree and registered nurses with a diploma in nursing. The findings on the likelihood of NMTs with a diploma embracing FCC practices have not been reported in previous studies. Conversely, most previous studies have concluded that staff nurses were less likely to embrace FCC practices due to their low education level (
      • Alabdulazziz H.
      • Moss C.
      • Copnell B.
      Paediatric nurses' perceptions and practice of family-centred care in Saudi hospitals: A mixed methods study.
      ;
      • Coyne I.
      • Murphy M.
      • Costello T.
      • O'Neill C.
      • Donnellan C.
      A survey of nurses' practices and perceptions of family-centered care in Ireland.
      ;
      • Ladak L.A.
      • Premji S.S.
      • Amanullah M.M.
      • Haque A.
      • Ajani K.
      • Siddiqui F.J.
      Family-centered rounds in Pakistani pediatric intensive care settings: Non-randomized pre- and post-study design.
      ;
      • Matziou V.
      • Manesi V.
      • Vlachoti E.
      • Perdikaris P.
      • Matziou T.
      • Chliara J.I.
      • Mpoutopoulou B.
      Evaluating how pediatric nurses perceive the family-centred model of care and its use in daily practice.
      ).
      • Lake E.T.
      The nursing practice environment.
      concluded that despite nurses higher or lower education status, the context in which nurses work added value to the acquisition of the fundamental principles of a phenomenon.
      • Mc Hugh D.M.
      • Lake T.L.
      Understanding clinical expertise: Nurse education, experience, and the hospital context.
      indicated that nurses' basic or generic knowledge of a phenomenon had the potential to enhance the acquisition of expertise that was fundamental to the provision of quality nursing care. The current findings therefore suggested that the NMTs with a diploma were also important in implementing current practices of FCC. This finding may likely explain why the NMTs in this study were more likely to implement practices of FCC that they perceived as necessary compared with the registered nurses.
      Different wards were associated with a significant influence on the scores in the current practices domain. The linear regression model demonstrated that the nurses who worked in surgical wards were more likely to implement current practices of FCC to a greater extent compared with nurses in oncology, orthopedic, nutrition rehabilitation units, and general wards. Given that all the above wards admitted children who would receive longer surgical and medical care than those in general wards in Malawi, the current findings suggested that working in chronic care wards was associated with a greater implementation of current practices of FCC. A few studies have identified the working environment as a predictor of current practices of FCC (
      • Dall'Oglio I.
      • Mascolo R.
      • Gawronski O.
      • Tiozzo E.
      • Portanova A.
      • Ragni A.
      • Latour J.M.
      A systematic review of instruments for assessing parent satisfaction with family-centered care in neonatal intensive care units.
      ;
      • Murphy M.
      • Fealy G.
      Practices and perception of family-centred care among children’s nurses in Ireland.
      ). One study reported that nurses in paediatric rehabilitation units were more likely to implement current practices of FCC (
      • Dall'Oglio I.
      • Mascolo R.
      • Gawronski O.
      • Tiozzo E.
      • Portanova A.
      • Ragni A.
      • Latour J.M.
      A systematic review of instruments for assessing parent satisfaction with family-centered care in neonatal intensive care units.
      ).
      • Dall'Oglio I.
      • Mascolo R.
      • Gawronski O.
      • Tiozzo E.
      • Portanova A.
      • Ragni A.
      • Latour J.M.
      A systematic review of instruments for assessing parent satisfaction with family-centered care in neonatal intensive care units.
      argued that the current FCC principles were easier to implement in rehabilitation settings given the chronic nature of the patients' diseases, which prolonged families' experiences. However, the finding that working in a general ward was a significant predictor of current practices of FCC is important. General wards admit children with acute conditions, such as malaria, pneumonia, and anaemia, with an average length of stay of less than five days (
      • Malawi Ministry of Health
      Quality Management Policy for the Health Sector.
      ). Literature on the contribution of general wards to FCC is not well documented, and as such, this finding should be subjected to further research.
      Studies have indicated that married nurses were more likely to influence FCC practices than single nurses (
      • Dall'Oglio I.
      • Mascolo R.
      • Gawronski O.
      • Tiozzo E.
      • Portanova A.
      • Ragni A.
      • Latour J.M.
      A systematic review of instruments for assessing parent satisfaction with family-centered care in neonatal intensive care units.
      ;
      • Letourneau N.
      • Elliott M.R.
      Pediatric health care professionals’ perceptions and practices of family-centered care.
      ). However, the current findings demonstrated that the widowed and separated nurses were more likely to embrace current practices of FCC than both the married and single nurses. Few studies have reported this association, making these findings new in literature on FCC. However, these findings may be linked to the nurses' past marriage experiences.
      • Young J.
      • McCann D.
      • Watson K.
      • Pitcher A.
      • Bundy R.
      • Greathead D.
      Negotiation of care for a hospitalised child: Nursing perspectives.
      ascertained that married nurses were both more empathetic and sympathetic than unmarried nurses.
      The association between nurses' religious denomination and current and perceived necessary practices of FCC has not been elaborated before. This study demonstrated that the nurses whose religious denomination was Moslem, Buddhist, Hindi, or Seventh-day Adventist were more likely to implement current practices of FCC, and those who were Moslems, Buddhists, or Hindi were more likely to implement practices of FCC that they perceived as necessary. The influence of religious denominations on individuals' practices, perceptions, and beliefs about health, outside the FCC context, have been reported (
      • Guerrero A.D.
      • Chen J.
      • Inkelas M.
      • Rodriguez H.P.
      • Ortega A.N.
      Racial and ethnic disparities in pediatric experiences of family-centered care.
      ;
      • Srivastava R.H.
      Culture, religion and family-centered care.
      ). While the current study presented only limited evidence on the influence of religion on FCC practices, it suggested the potential of integrating religious contexts into FCC to meet families' and their children's healthcare needs. As such, the values and beliefs of the IPFCC framework and FCC in general were supported by this study (
      • Guerrero A.D.
      • Chen J.
      • Inkelas M.
      • Rodriguez H.P.
      • Ortega A.N.
      Racial and ethnic disparities in pediatric experiences of family-centered care.
      ).
      Similarly, cultural background had a significant influence on the nurses' current practices, as the nurses who had a Tumbuka or a Yawo cultural background were more likely to implement current practices of FCC, whereas the nurses who had a Tonga or a Ngonde cultural background were less likely to implement current practices of FCC, although they highly valued them. The predictive nature of cultural backgrounds is particularly important in Malawi because the country is culturally diverse, with more than 15 ethnic and cultural groups (
      • Chilivumbo A.B.
      Malawi’s culture in the national integration.
      ). Studies on the contribution of cultural backgrounds in the context of FCC are limited, as are studies that linked the influence of cultural backgrounds to its likelihood of influencing the implementation of current practices of FCC. However, these previous studies only reported that respecting families' cultural backgrounds was the foundation of FCC (
      • Crocker E.
      • Webster P.D.
      • Johnson B.H.
      Developing patient- and family centered vision, Mission, and philosophy of care statements.
      ;
      • Shaul R.Z.
      Paediartic patient and family centred care: Ethical and legal issues.
      ;
      • Srivastava R.H.
      Culture, religion and family-centered care.
      ). These findings are supported by the IPFCC framework, which highlights that child- and family-centred care and cultural background are complementary (
      • Abraham M.
      • Moretz J.G.
      Implementing patient- and family-centered care: Part I – Understanding the challenges.
      ;
      • Shaul R.Z.
      Paediartic patient and family centred care: Ethical and legal issues.
      ). In light of the complexity of cultural backgrounds (
      • Nicholas D.B.
      • Keilty K.
      • Karmali K.
      Paediatric patient-centred care: Evidence and evolution.
      ), the current findings have provided a platform for further studies on the specific contribution of cultural backgrounds to FCC in the study's settings.
      The nurses who worked in mission and central hospitals were more likely to support FCC practices than those who worked in district hospitals. Research on the predictive nature of mission and central hospitals in FCC has not been well documented. However,
      • Berendes S.
      • Heywood P.
      • Oliver S.
      • Garner P.
      Quality of private and public ambulatory health care in low- and middle-income countries: Systematic review of comparative studies.
      concluded that healthcare providers in mission hospitals were more patient-centred than those in government hospitals.
      • Basu S.
      • Andrews J.
      • Kishore S.
      • Panjabi R.
      • Stuckler D.
      Comparative performance of private and public healthcare systems in low- and middle-income countries: A systematicreview.
      argued that mission and district hospitals were more concerned with disease burden management, while central hospitals were concerned with clients who needed chronic care. Moreover, as central hospitals focused on specialised care, they were more likely to provide care that was more client-centred (
      • Basu S.
      • Andrews J.
      • Kishore S.
      • Panjabi R.
      • Stuckler D.
      Comparative performance of private and public healthcare systems in low- and middle-income countries: A systematicreview.
      ).

      Practice implications

      The findings on the discrepancies between current and perceived necessary practices of FCC from the perspective of nurses in Malawi are of utmost importance and may help to limit the extent of such discrepancies by identifying the facilitators of and barriers to implementing necessary practices of FCC. Hence, hospital administrators should support nurses with guidelines and develop strategies to facilitate the holistic implementation of necessary practices of FCC, such as parent-to-parent support groups and continuing professional education programmes on FCC (
      • Coyne I.
      • Murphy M.
      • Costello T.
      • O'Neill C.
      • Donnellan C.
      A survey of nurses' practices and perceptions of family-centered care in Ireland.
      ). The identification of the predictors of the implementation of FCC in this study has provided a basis for researching and testing FCC interventions in future studies. In addition, the current findings suggested that continuing FCC education was needed to support nurses from backgrounds that have reported less implementation of FCC, such as single nurses and those in district hospitals. Based on the discrepancies reported, research is needed to explain how the identified factors contribute to these discrepancies and their impact on the implementation of FCC.

      Limitations

      The use of a cross-sectional study failed to establish causality, and the self-reported data collection method may have been subject to bias. These limitations may have implications on the generalisability of these findings and their interpretation. Therefore, the findings should be carefully interpreted and generalised based on the study settings.

      Conclusion

      The current findings suggested that nurses in Malawi implemented FCC widely and valued FCC practices highly. The identified discrepancies between current and perceived necessary practices suggested that there were barriers to the implementation of necessary practices of FCC. The differences between the current findings and those of previous studies supported the notion that the implementation of FCC varied across countries. Thus, there is a need for international collaboration on FCC research to critique and generate consensus on the theory of FCC (
      • Foster M.
      • Shields L.
      Bridging the child and family centered care gap: Therapeutic conversations with children and families.
      ;
      • Shields L.
      Why international collaboration is so important: A new model of care for children and families is developing.
      ). The current study found that socio-demographic characteristics such as education level, marital status, professional level, cultural background, and ward type were both the predictors of and the factors in the significant differences between current and perceived necessary practices of FCC, which signified their importance in promoting the implementation of FCC practices to meet families' and their children's healthcare needs. Future researchers should consider these aspects when designing, developing, and testing the theory of FCC and implementing FCC interventions.

      Authorship credit statement

      PGMC, CHW, CLW: Conceptualization; Writing - original draft; Formal analysis; Investigation; Methodology; Supervision; KCC: Validation; Visualization; Data curation. MSSN & KCC: Writing - review & editing.

      Funding

      The authors declare that they have received no grants from any funding body or agency in commercial, public, or not-for-profit sectors.

      Declaration of Competing Interest

      All authors have no potential conflicts of interest to declare regarding this publication.

      Appendix A. Supplementary data

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