Direct family participation in care in adult intensive care: A Walker and Avant concept analysis.

BACKGROUND: Family participation is increasingly recognised in adult intensive care units (ICUs). However, family participation, involvement and engagement are often used as umbrella terms encompassing presence, emotional support, communication, shared decision-making and direct care. Consequently, the meaning and professional boundaries of direct family participation in care (DFPC) remain unclear. AIM: To clarify the defining attributes, antecedents, consequences, empirical referents and operational definition of DFPC in adult intensive care. METHODS: Walker and Avant's method guided the analysis. Six databases were searched from inception to 7 March 2026 for publications relevant to DFPC in adult ICUs. Two researchers independently screened records, extracted and coded concept-relevant data, and cross-checked their findings. Disagreements were resolved through discussion, with unresolved discrepancies referred to the research team. Evidence units were synthesised using iterative qualitative content analysis. RESULTS: Ninety-two publications (1999-2026) were included. DFPC was conceptualised as a voluntary, professionally guided form of family participation in selected bedside care-related activities, enacted in accordance with patient autonomy and through meaningful family-patient interaction. The defining attributes were patient autonomy, adaptive task participation, guided professional collaboration and therapeutic relational interaction. Antecedents comprised patient-family-professional readiness alignment, unit readiness, institutional support and sociocultural acceptability. Consequences spanned patient, family, professional and system levels and reflected a condition-dependent resource-risk paradox. Empirical referents comprised autonomy, behavioural, process and relational indicators. CONCLUSIONS: DFPC is a distinct, professionally guided direct-care dimension of family participation in adult ICUs, providing a conceptual foundation for measurement, intervention development and implementation research. IMPLICATIONS FOR CLINICAL PRACTICE: DFPC should be optional, structured and adapted to patient-family-professional readiness while respecting patient autonomy. Healthcare professionals should collaborate according to task complexity and clinical risk to select activities, clarify roles, prepare family members, supervise participation and modify or discontinue it as conditions change.