The moderating effects of nurses’ characteristics on the perceptions and practices of family-centered care for chronically ill children and their families in Saudi Arabia

The conceptual framework of this study is based on the characteristics of nurses, which include sociodemographic factors and personal attributes that are hypothesized to influence their perceptions and practices of FCC. Sociodemographic factors encompass the nurses' age, gender, marital status, education level, and years of work experience. The attributes of nurses include professional competence, interpersonal skills, job commitment, and self-awareness [31]. The Nurses’ attributes adapted from The person-centered nursing framework which, organizes key concepts into inner and outer circles [31]. The outer circle emphasizes the attributes of nurses included in this study, followed by the care environment, while the inner circle represents centered care. This structure indicates that establishing nurses’ attributes is essential for fostering a supportive care environment, influencing the quality of centered care [31]. Previous research has noted the impact of nurses' characteristics and organizational factors on FCC but has not fully examined their direct and indirect effects [32]. The framework, adaptable to all ages, including child-centered care [31], suggests that effective centered care arises from nurses’ attributes [31, 33], ultimately leading to positive health outcomes. Regarding perceptions and practices of the FCC, the adapted model includes several integral dimensions: Family as a constant presence, Collaboration between families and healthcare professionals, Recognition of family strengths and individuality, Sharing information with families, Parent-to-parent support, Addressing developmental needs, Providing emotional and financial support for families, Designing healthcare delivery systems that involve families, Offering programs and emotional support for staff members [34, 35].

Accordingly, the following hypotheses were developed; H1: Nurses' perceptions of FCC are positively associated with their FCC practices for chronically ill children and their families, H2: Specific sociodemographic factors, such as marital status, may moderate the relationship between nurses’ perceptions of FCC and their practices, H3: Professional competence does not significantly moderate the relationship between nurses' perceptions of FCC and their practices. This study aimed to test these hypotheses, as illustrated in the conceptual framework (Fig. 1). The objectives of this study were 1) to assess nurses’ perceptions of FCC and their actual practices in delivering care to chronically ill children and their families in Saudi Arabia. 2) To identify and analyze the differences between nurses' perceptions and the practical application of FCC principles. 3) Determine which nurse characteristics most significantly influence FCC perception and implementation. 4) To explore the moderating role of nurses’ characteristics, including sociodemographic factors (e.g., age, marital status, and education level) and professional attributes (e.g., interpersonal skills, job commitment, and self-awareness) in the relationship between FCC perceptions and practices.

This manuscript is part of a larger project. This research employed a multicenter cross-sectional design, conducted across three major tertiary hospitals in Saudi Arabia, providing services for chronically ill children. The first hospital is a tertiary teaching facility offering specialized pediatric care to the general population, staffed by 290 nurses, and housing 153 beds. The second facility, a Ministry of Health-operated tertiary hospital, functions as a referral center for specialized services, with 357 nurses across different pediatric units and 252 beds. The third institution is a magnetic hospital with 158 nurses and 85 beds, caring for children across various pediatric units. All three hospitals incorporated FCC into their policies.

A convenience sample of 405 nurses was surveyed online between February and August 2023 using an electronic link. Nurses who had worked with chronically ill children (including infants, toddlers, and young children) for at least six months were eligible to participate. Chronic illnesses refer to long-term conditions, diseases, or disabilities. The total response rate in the current study was 50.31%, which may appear modest; however, this response rate aligns with similar studies conducted in nursing research and healthcare settings [36, 37].

The study utilized validated tools to assess the variables of interest. Nurses' characteristics, including sociodemographic factors and nursing attributes, were measured using the Person-Centered Practice Inventory-Staff (PCPI-S) and the Family-Centered Care Questionnaire-Revised (FCCQ-R) [23, 24, 31]. Both tools demonstrated robust psychometric properties, providing reliable and valid measurements for assessing FCC practices and perceptions in current study’ cultural context [38].

Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) (version 29) and SPSS PROCESS macro version 4. [43]. During the data cleaning process, frequency distributions were used to examine the extent of missing data or invalid values for each variable [44]. The skewness and kurtosis values were examined to determine the normality of data distribution. The skewness measures the symmetry of the distribution, with values close to zero indicating symmetry. Kurtosis evaluates the "peakedness" or flatness of a distribution. In this study, skewness values between -2 and 2 and kurtosis values between -7 and 7 were deemed acceptable, as these ranges are commonly used in healthcare research to indicate approximate normality [45]. All variables in this study fell within these acceptable ranges, confirming that the data distribution was sufficiently normal to proceed with the statistical analyses employed, such as Pearson's correlation and moderation analyses. Descriptive statistics were used to summarize participants' sociodemographic characteristics and study variables. The relationships between nurses' characteristics and study variables, including FCC perceptions and practices, were examined using Pearson’s correlation (r_p), Spearman’s rank-order correlation (r_s), and point-biserial correlation (r_pb), depending on the level of measurement. A paired t-test was used to evaluate differences between current FCC practices and perceptions.

To test this hypothesis, a moderation analysis was performed using the PROCESS macro, following model one [43]. In this analysis, FCC perception served as an independent variable, FCC practice was the dependent variable, and nurses' characteristics included age, gender, marital status, education level, years of experience, professional competence, interpersonal skills, job commitment, and self-awareness. The analysis was conducted ten times to test the interaction effect of each characteristic on the relationship between FCC perception and practice. Statistical significance was determined at p < 0.05. To ensure robustness, 95% confidence intervals (CIs) for interaction effects were obtained through bias-corrected bootstrapping with 5,000 resamples.

Table 2 presents the correlation results for the sociodemographic characteristics and study variables. No significant correlations were evident between the following: first, FCC perception and its dimensions and nurses’ sociodemographic characteristics; and second, the total FCC perception scale and nurses’ sociodemographic characteristics. Looking at the FCC practice dimensions and the total FCC practice scale, only age and education level were significantly correlated with some items and scale. Based on Pearson's r correlation, age was weakly but positively and significantly correlated with family strength and individuality (r_p = 0.13, n = 405, p = 0.00), developmental needs (r_p = 0.10, n = 405, p = 0.02), emotional and financial support (r_p = 0.11, n = 405, p = 0.02), emotional support for staff (r_p = 0.14, n = 405, p = 0.00) in FCC practice, and the total FCC practice scale (r_p = 0.11, n = 405, p = 0.02). Based on Spearman's rho correlation, education level was weakly but negatively and significantly associated with the parent-to-parent support domain on the FCC practice scale (r_s = -0.12, n = 405, p = 0.01). Among the domains (indicators) of nursing attributes, only knowing one’s self was significantly negatively and weakly correlated with gender (r_pb = -0.10, n = 405, p = 0.03), based on point-biserial correlation. Furthermore, education level was positively correlated with knowing oneself (r_s = 0.12, n = 405, p = 0.01).

A paired sample t-test was conducted to compare the differences between nurses’ perceptions and practices of FCC among chronically ill children (Table 3). There was a significant difference in the total scores for the FCC perception and practice dimensions. First, there was a significant difference in the total FCC perception score (M = 4.07, SD = 0.60) and total FCC practice (M = 3.88, SD = 0.59), t (404) = -9.80, p = 0.001. Perception of family as a constant (M = 4.00, SD = 0.74) was higher than that of practicing family as a constant (M = 3.83, SD = 0.76), t (404) = -7.24, p = 0.001. The perception of parent/professional collaboration (M = 3.97, SD = 0.73) was higher than that of practicing parent/professional collaboration (M = 3.81, SD = 0.76), t (404) = -7.58, p = 0.001. Perception of family strengths and individuality (M = 4.15, SD = 0.68) was higher than that of practicing family strengths and individuality (M = 3.92, SD = 0.72), t (404) = -7.82, p = 0.001. The perception of sharing information (M = 4.09, SD = 0.67) was higher than that of sharing information (M = 3.91, SD = 0.70), t (404) = -8.07, p = 0.001. Furthermore, the perception of parent-to-parent support (M = 3.98, SD = 0.74) was greater than that of parent-to-parent support (M = 3.71, SD = 0.80), t (404) = -8.16, p = 0.001. Perception of family developmental needs (M = 4.11, SD = 0.66) was higher than that of practicing family developmental needs (M = 3.92, SD = 0.71), t (404) = -7.16, p = 0.001. The perception of emotional and financial support to the family (M = 4.05, SD = 0.67) was higher than that of practicing emotional/financial support needs (M = 3.88, SD = 0.69), t (404) = -6.78, p = 0.001. Perception of the healthcare delivery system design (M = 4.10, SD = 0.61) had a higher score than how the system functioned in practice (M = 3.91, SD = 0.69), t (404) = -7.65, p = 0.001. The perception of emotional support for staff (M = 4.12, SD = 0.65) was also higher than that of such support in practice (M = 3.92, SD = 0.70), t (404) = -7.01, p = 0.001.

Model one was followed in this analysis of the moderation effect [32]. FCC practice was regressed on FCC perception and its interaction with moderators (age, gender, marital status, education level, years of experience in the job, professionally competent, having interpersonal skills, being committed to the job, and knowing one’s self). With age as a moderator in the first analysis, the overall model explained 64.1% of the variance (F [3.000] = 238.803, p < 0.001). The interaction between FCC perception and age was not significant (b = 0.046, 95% C.I. [-0.003], p = 0.012); thus, age did not significantly moderate this relationship. In the second analysis, with gender as a moderator, the overall model explained 63.1% of the variance (F [3.000] = 228.729, p < 0.001). The interaction between FCC perception and gender was not significant (b = 0.086, 95% C.I. [-0.153], p = 0.481); therefore, gender did not significantly moderate this relationship. In the third analysis, with marital status as a moderator, the overall model explained 64.3% of the variance (F [3,000] = 240.779, p < 0.001). The interaction between FCC perception and marital status was significant (b = 0.122, 95% C.I. [0.024], p = 0.014). Thus, marital status significantly moderated this relationship. In the fourth analysis, with educational level as a moderator, the overall model explained 63.4% of the variance (F [3.000] = 231.677, p < 0.001). The interaction between perception and education level was not significant (b = -0.060, 95% C.I. [-0.177], p = 0.305); therefore, education level did not significantly moderate this relationship. In the fifth analysis, with years of work experience serving as a moderator, the overall model explained 63.8% of the variability (F [3.000] = 235.543, p < 0.001).

The interaction between perception and years of work experience was not significant (b = 0.021, 95% C.I. [-0.022], p = 0.334). Therefore, years of work experience does not significantly moderate this relationship. The sixth analysis, which used professionally competent as a moderator, explained 63.8% of the variability (F [3.000] = 235.943, p < 0.001). The interaction between perception and professional competence was not significant (b = 0.592, 95% C.I. [-0.017], t = 1.515, p = 0.130); consequently, professional competence did not significantly moderate this relationship. In the seventh analysis, with interpersonal skills as a moderator, the model explained 64.6% of the variance (F [3.000] = 244.589, p < 0.001). The interaction between perception and interpersonal skills was significant (b = 0.131, 95% C.I. [0.045], p = 0.002) thus and interpersonal skills significantly moderated this relationship. In the eighth analysis, with commitment to the job as a moderator, the overall model explained 64.2% of the variance (F [3.000] = 240.299, p < 0.001). The interaction between perception and job commitment was significant (b = 0.096, 95% C.I. [0.012], p = 0.024). Therefore, commitment to the job significantly moderated this relationship. Referring to the ninth analysis, where knowing oneself was the moderator, the overall model explained 65.5% of the variance (F [3.000] = 254.539, p < 0.001). The interaction between perception and knowing one’s self was significant (b = 0.127, 95% C.I. [0.054], p = 0.000); therefore, knowing one’s self significantly moderated the relationship. Table 4 presents the results of the moderation.

The current study’s findings reveal significant discrepancies between nurses' perceptions of FCC and their current implementation. Nurses’ practice (M = 3.88, SD = 0.59) was found to be significantly lower than the total FCC perception score (M = 4.07, SD = 0.60) among nurses who provided care for chronically ill children and their families. These results align with studies conducted in Italy [46], the United States [47], and Canada [34], indicating that nurses in the Saudi healthcare system practice FCC at levels comparable to those in other countries. In contrast, the lower FCC scores reported in Thailand suggest that cultural and systemic differences may hinder the adoption of FCC there [48]. These gaps highlight the need to contextualize FCC interventions based on cultural and healthcare system dynamics [49‐51]. Although there were differences between the nurses’ perceptions of FCC and their current practices, there was a significant positive relationship between them. This means that nurses’ positive perceptions of FCC can enhance their practices for chronically ill children. This is consistent with previous studies showing that nurses’ positive perceptions and attitudes toward FCC practices make implementation more likely [18, 19, 22, 23]. This is in line with the current scoping review, which emphasizes the significance of nurses’ attitudes in fostering a friendly, accepting, and welcoming environment for families, thereby facilitating the aspects of FCC [50]. Nursing leaders should focus on changing their staff members’ negative perceptions to effectively implement FCC for chronically ill children and their families [23]. Experiential learning and mentoring can help modify nurses’ values and attitudes towards FCC [52].

This study found a significant positive correlation between age and the current FCC practice dimensions. The ability to implement FCC may be influenced by the nurses’ years of experience and the independent decisions they make in their practice. Experienced nurses possess unique knowledge and skills that enhance the functioning of healthcare centers [53]. Conversely, some studies, such as those conducted in Greece, have shown that younger nurses are more likely to adopt FCC practice [20]. These differences may stem from various factors, including organizational policy, care environment, and nurses’ confidence in applying for FCC [16, 18, 19]. The current study’s findings align with those of a previous study conducted in Malawi, which indicated that nurses over the age of 40 are more likely to practice FCC [54]. These results underscore that, in contrast to younger nurses, older nurses tend to be more confident and willing to practice FCC despite facing challenges [54]. Moreover, in the current study, nurses with an associate degree in nursing tended to practice FCC more than nurses with bachelor’s degrees. This outcome disagrees with studies reporting that nurses with postgraduate qualifications were more likely to deploy FCC [20, 34, 54]. It should be noted that this finding is inconsistent with other studies indicating that low educational levels can hinder nurses' ability to practice FCC [18, 20, 35, 55]. This could be explained by the fact that nurses with higher qualifications are assigned duties that limit their time to providing FCC. Alternatively, nurses working in the Saudi healthcare system with higher qualifications differ from other nurses, which might be due to the lack of integration of FCC principles into their training and nursing curricula, particularly those who provide care for pediatric patients and their families [9]. Research has suggested that education plays a crucial role in enabling nurses to implement FCC effectively [19, 20, 55]. An interventional study discovered that educating nurses in family-centered care had a positive effect on their clinical practices and attitudes towards pediatric patients [56].

Interestingly, the strength of the relationship between FCC perception and practice is influenced by the moderating effects of nurses’ characteristics, such as marital status, effective interpersonal skills, commitment to the job, and knowing one’s self. Examining these moderating effects contributes to the literature and helps address the existing gap in research, particularly in the context of chronically ill children and family-centered care and FCC. In terms of the moderating effect of nurses’ marital status, the findings highlight that married women might have a more positive perception of FCC and its practices. Married nurses might show more empathy and positive attitudes towards pediatric patients than non-married nurses [57, 58], which helps them implement FCC based on what they perceive. Married nurses may have children themselves, and this experience means they are familiar with their experience [20]. This is consistent with previous studies’ findings that having children moderates the relationship between FCC perception and practice among Malawi nurses [25]. In addition to sociodemographic factors, professional attributes, such as effective interpersonal skills, commitment to the job, and knowing one’s self, play a crucial role in shaping FCC practices. Nurses’ communication with chronically ill children’s families is vital for making decisions, negotiating care aspects, and developing effective nurse-child-family relationships [59]. Previous studies, including those by Malepe et al. (2022) [22] and Wong et al. (2023) [23], have demonstrated that effective communication, counseling, and negotiation skills are essential for promoting family collaboration in FCC. A scoping review revealed that building a professional relationship with families enables nurses to effectively practice FCC [50]. Some studies have shed light on communication and negotiation skills as facilitators influencing nurses’ FCC practices [7, 17, 19, 20, 35, 55, 60, 61]. Nurses with a higher level of effective interpersonal skills, including verbal and nonverbal communication skills had more positive perceptions of FCC, which positively helped the accompanying practices [31, 59]. Therefore, developing interpersonal skills strengthens the relationship between FCC perception and practice in chronically ill children, and facilitates their implementation. Interpersonal skills in caring for chronically ill children must be integrated into nursing curricula and education [62]. Moreover, being committed to the job refers to nurses’ dedication to caring for ill children and their families [31]. This study highlights that nurses with a higher level of commitment exhibit a more positive perception of FCC, leading to its practice. Knowing oneself also moderated the relationship between FCC perceptions and practices. Nurses who understand themselves through self-awareness and reflection on personal experiences and workplace situations have a higher perception of the necessity of FCC [31]. Knowing one’s self can positively contribute to effective nursing routines [63, 64]. This means that knowing oneself influences the relationship between FCC perception and its implementation to help care for chronically ill children. Interventional support programs for nurses that enhance their knowledge of self-related activities may be useful for enhancing FCC implementation. However, only a few studies have examined this moderating effect.

Although nurses recognize the importance of FCC, their ability to implement it is hindered by several persistent barriers. Personal attributes, such as limited communication skills affect nurses' capacity to provide FCC [22]. Additionally, a lack of skills in information sharing, counseling, interviewing, and negotiation, as well as a lack of commitment to FCC [24]. Other systemic barriers also obstruct the practice of FCC in healthcare settings. These include the absence of an FCC philosophy within hospitals. insufficient staffing, and a heavy workload [21, 23, 48]. Furthermore, the lack of education and training programs and limited authority for nurses to share information contribute to these challenges. Addressing these barriers is crucial to narrowing the gap between perceptions and practices [18, 19, 21, 52].

The current study highlights the need for targeted interventions to bridge the gap between perception and practice in FCC. Emphasizing nurses’ interpersonal and communication skills is crucial for their successful implementation. Policy reforms, education, and training programs should address discrepancies between perceptions and practices. These initiatives should address systemic barriers and enhance nurses’ skills, thereby fostering an environment that promotes the principles of FCC. In addition, it is vital to integrate FCC concepts into nursing curricula and to provide ongoing training to improve competencies. Furthermore, FCC should incorporate the hospital’s mission, establish supportive policies, maintain adequate staffing levels, reduce nurses’ workloads, provide training, and empower nurses with decision-making authority [32, 65]. Modifying healthcare system policies to support nurses is essential for the implementation of FCC. Well-defined organizational policies and guidelines serve as foundational elements that facilitate FCC [51]. The current study, conducted in Magnet and Baby-Friendly hospitals that integrated FCC concepts into their policies and procedures, reflects a high level of awareness and implementation of FCC among nurses. This positive outcome suggests that these hospitals effectively incorporated FCC principles into their workflow. However, obstacles persist, and the challenges faced by nurses in implementing FCC in Magnet and Baby-Friendly hospitals differ across organizations. Furthermore, future studies should investigate the impact of unexamined variables, such as emotional intelligence and teamwork, on perceptions and practices of FCC. Longitudinal research is necessary to understand how nurses’ perceptions of FCC evolve over time, and how these perceptions affect actual practices. This research will help to identify effective strategies for improving the implementation of FCC and the quality of care for chronically ill children and their families.

The findings of this study on a tested conceptual framework can serve to improve nurses' clinical practice regarding chronically ill children and their families. Specifically, influential factors related to nurses' attributes can be used to develop and test evidence-based interventions. These findings can also be used to design interventions aimed at enhancing nurses' FCC practices and improving the quality of care provided to these children. For instance, developing training programs that integrate FCC and nurses' attributes into nursing curricula can enhance nurses’ skills, perceptions, and practices. Further studies using a randomized clinical trial design are needed to test the effectiveness of addressing nurses' attributes and the context in which care is provided on outcomes such as quality of care using objective measures. In addition, those in charge of the healthcare system can use these findings to provide the necessary resources and support for nurses so that FCC practices can be implemented, especially in pediatric units.

Although this study has shown some benefits, there are some limitations to consider. However, this study has several limitations that need to be addressed. Participants were recruited through a convenience sample, which limits the generalizability of the findings. Furthermore, only three major hospitals in Saudi Arabia were case study sites, which limited the external validity of the study. Using several healthcare locations may have resulted in nurses providing a greater variety of answers and perspectives that reflect very different organizational policies, procedures, cultures, and client bases. The scale was specifically culturally adapted to the Saudi context, and needs to be tested and evaluated in other Arabic contexts. Moreover, the questionnaire was designed on a self-report basis, and the comments elicited by participating nurses could be biased or very context-specific. Furthermore, the use of cross-sectional design hinders the inference of causation.