Families play a major role in healthcare systems, and it is thus important for nurses to not only focus on the patient but also engage with their respective families (Chironda & Brysiewicz 2021; Hagedoorn et al. 2021). Family involvement in healthcare services has been shown to be an essential component of nursing care, which benefit both the family and patient (Svavarsdottir et al. 2018). The growing body of available literature globally reveals fewer adverse events, better self-management, fewer diagnostic tests, decreased use of health services and shorter lengths of stay in the hospital to be associated with family engagement in care (Aronson et al. 2009; Abrams et al. 2013; Goodridge et al. 2018). In addition, the quality of nurse-patient-family relationships, overall improvement in health literacy, self-care in chronic disease management, clinical decision-making and patient safety are also enhanced (Svavarsdottir et al. 2018).

Nursing professionals, including student nurses, therefore need to identify and meet healthcare needs of families to promote family engagement – a fundamental goal of family nursing (Imanipour & Kiwanuka 2020). Hence, the concept of family nursing practice (FNP) becomes a central goal in facilitating family nurse relationships, consequently family engagement in healthcare settings (Misto 2018). Nurses, including the student nurses they preceptor during clinical placements, are expected to reflect on their attitudes in working with families including critically appraising their family nursing practices in terms of knowledge, skill, confidence and satisfaction. Similarly, promoting interaction and reciprocity in the nurse-family relationship (NFR) in terms of planning care, promoting family participation and recognising biases and reciprocity in the therapeutic relationship is also crucial (Misto 2018; Simpson & Tarrant 2006).

While much of the current emphasis of nursing care practice is on families (Broekema et al. 2021; Eggenberger & Sanders 2016; Imanipour & Kiwanuka 2020; Meiers, Eggenberger & Krumwiede 2018), it remains a challenge for student nurses to involve families in care (Fitzgerald & Ward 2019). This is magnified in the African countries where family nursing is not a recognised specialty area of nursing (Chironda, Jarvis & Brysiewicz 2023). Kiik et al. (2017) highlighted the lack of family focussed nursing education, with the current focus on the Biomedical Model identified as one of the major factors hindering nurses and other health care professionals in collaborating with families. Despite these obstacles, family nurse researchers across the globe continue to encourage nursing undergraduate programmes to include family nursing theory, family nursing constructs and family nursing interventions to enhance knowledge and skills training in FNP, thus enabling the students to meet families’ needs and deliver optimal family engagement (Eggenberger & Regan 2010; Coyne 2015; Meiers et al. 2018; Skene et al. 2019; Chironda et al. 2023).

Although studies of FNPs are gaining momentum in global literature, the available evidence has largely targeted the qualified nursing professionals (Imanipour & Kiwanuwa 2020; Misto 2014, 2018; Naef et al. 2020), with limited studies exploring this phenomenon in undergraduate student nurses. Hence the aim of the study was to explore the undergraduate nurse perceptions of FNPs in a selected institution in KwaZulu–Natal (KZN).

The undergraduate student nurses’ critical appraisal of their FNP, perceptions of interaction and reciprocity in the NFR including the challenges, advantages and examples of how they worked with families during their nursing practicum were explored in this descriptive study.

The overall mean total score indicated low FNPs for undergraduate nursing students in keeping with the findings of a study done by Lee, Leung and Mak (2012) in Hong Kong. While there are limited studies on student nurses’ assessment of their FNP, the available literature has explored qualified nurses’ perceptions across the globe (Imanipour & Kiwanuka 2020; Misto 2014; Naef et al. 2020, 2021). The studies done by Misto (2014) and Naef et al. (2020) revealed high FNPs while some indicated moderate practices (Imanipour & Kiwanuka 2020; Naef et al. 2021). This is not surprising as family nursing content in undergraduate curricula is still being delivered embedded within other subject areas like community health nursing in many nursing schools (Honda 2021).

Similarly, the South African Nursing Council (SANC) undergraduate curriculum, both the old (R425 registered nurse) and new (R171 Professional Nurse and Midwife), includes a community nursing qualification with an embedded FNP (SANC 2021). The same applies to the postgraduate programmes in Primary Health Care (PHC) and community health nursing. Hence, both 2nd and 3rd year undergraduate nursing students embraced their current FNPs through family assessments including giving family health education during community nursing practice. However, this seems to be inadequate as the students lacks more in-depth knowledge and the skill of FNP.

A greater number of female nursing students’ representation relate to nursing being a feminine gendered profession and this deters most men from choosing it as a lifelong career (Van der Cingel & Brouwer 2021). While the proportion of undergraduate student male nurses in the sample was low, they still exhibited a significant low family practice than their female counterparts. These findings might be because of differences in culture and communication styles in males and females (Cranley et al. 2022). In the South African cultural context, females from the young age are taught to perform motherly duties (Bassey & Bubu 2019), this might explain why undergraduate female nursing students in the current study had better FNPs. Similarly, males and females have different communication skills because of differences in one’s socialisation (Cranley et al. 2022). According to Arreciado Marañón, Rodríguez-Martín and Galbany-Estragués (2019), male nurses limit their emotional involvement and take control over the boundaries of relationships with families as compared to their female colleagues. Contrarily, a study by Hoplock et al. (2019) revealed no significant association between gender and nurses’ attitudes towards the importance of family involvement in nursing care.

Findings of the study confirm 3rd year nursing students to have rated their FNPs better than 2nd year students. Although there are no studies to affirm or contrast the findings in the current study, similar trends are shown in qualified nurses, where nurses with graduate education exhibited higher FNPs than those with bachelors (Svavarsdottir et al. 2018). Similarly, on FNP-PA subscale (Simpson & Tarrant 2006), 2nd year student nurses expressed lower critical appraisal of family nursing than 3rd year students thus indicating less confidence especially in skills, knowledge of family systems and satisfaction in working with families. Eggenberger, Krumwiede and Young (2015) reported lack of confidence in nurses’ ability to meet the needs of families. Moreover, student nurses avoid families, and they always feel anxious when meeting with them (Shajan & Snell 2019) probably because of their limited knowledge and skills. This is expected as there is little training available on nursing of families (Wittenberg et al. 2020) and most nursing education has not fully embraced the incorporation of family nursing into their undergraduate curriculums (Chironda et al. 2023). Undergraduate nursing programmes need to teach family nursing to evoke ‘thinking family’ in students’ nursing practice (Fast Braun, Hyndman & Foster 2010).

The need for more education about family nursing and involving families in the care of patient is apparent as student indicated that they are inadequate and ill prepared in their current training, thus concurring with the findings from Kaakinen et al. (2018) and Gutiérrez-Alemán et al. (2021). Sadly, students also felt undermined with family members dominating and purporting to know what is best for the patient. Therefore, it is the duty of the nurse educators to create and implement curriculum centred on FNP (Meiers et al. 2018). It has been suggested that using an educational intervention on family members in health settings have helped nurses to ‘think family’ with improved competence in family nursing conversations (Broekema et al. 2018).

Similarly, low perceptions of interaction and reciprocity in the NFR were identified on the FNP-NFR subscale especially in the 2nd year students, thus contrasting the findings of Lee et al. (2012). While Kydonaki et al. (2019) emphasised the importance of frequent communication with families as the basis for establishment of rapport and trust, undergraduate nursing students confirmed refusal of families to open up enough to provide any information as they were not confident in their capabilities. Consequently, families could not avail correct or omit essential information because they cannot trust the nursing staff. While nurses have an ethical and legal obligation to engage families in nursing care (Shajan & Snell 2019), sometimes conflicting views either within the family or with the student nurses occur because of family feuds or differences in perspectives as revealed in the study, thus affirming the finding of Misto (2014, 2018). In support of this, an integrative review by Rainer, Schneider and Lorenz (2018) reveals inappropriate behaviour or hostility towards nursing staff by families, thus resulting in conflict between the parties.

Acquiring detailed information about the patient was indicated by the student nurses, thus showing families as valuable especially in vulnerable conditions such as hospitalisation (Barreto et al. 2022; Ruiz et al. 2022). Ability to plan individualised care and enhanced student NFR is another benefit of involving family thus confirming the findings of Shajan and Snell (2019) and Misto (2018). Coats et al. (2018) appreciated the importance of family presence in allowing nurses to get to know families better and their preferences for care. Further family assessments done by student nurses ranged from engagements, identifying healthcare needs, taking medical and surgical history and involving families to discuss patient condition including discharge planning, thus agreeing to the findings of Misto (2018). Moreover, a 14 2-h classes of teaching students to work with families enhanced the critical appraisal of FNP and reflections on the NFR in undergraduate nursing students in Hong Kong (Lee et al. 2012). Nursing curriculums with family nursing content have shown to improve students’ knowledge of family and instil a passion for family care in undergraduate programmes (Meiers et al. 2018).

Compared to 3rd year students, a lower critical appraisal of FNP and lower perceptions of interaction and reciprocity in the NFR were identified among 2nd year nursing students. Based on the p value of 0.001, there is a very low probability of 0.1% that these results are because of random chance, meaning the results are true. Obtaining detailed information, ability to plan individualised care and enhanced student NFR were advantages, while family conflict, maintaining confidentiality, ill prepared and absent family were challenges experienced in FNP. Although the SANC undergraduate and postgraduate programmes in PHC and community embraces family nursing, there is also need for an inclusive curriculum that promotes and advocates for family nursing within the undergraduate programme.