Family satisfaction in the intensive care unit: a quantitative and qualitative analysis

The communicative role of companion pets in patient-centered critical care

OBJECTIVE

This study examines a personal pet hospital visitation program dedicated to preserving the human-animal bond during chronic, critical, or terminal illness to understand the novel ways companion pets facilitate meaningful communication between patients, providers, and families in hospital settings.

METHODS

I thematically analyzed data collected through a variety of qualitative methods, including participant observation, informal and semi-structured interviews, and a review of organizational materials.

RESULTS

The presence of a patient's personal pet prompted stories and behaviors characterized by (1) compassion, (2) connection, and (3) response between patients, providers, and family members.

CONCLUSION

Personal pet hospital visits facilitate storied conversations, foster healing relationships, and offer alternative ways of knowing that can promote greater understandings of the patient's psychosocial context for more personalized care and improved well-being.

PRACTICE IMPLICATIONS

Patient-centered critical care requires meaningful consideration of a patient's health, well-being, and comfort. When appropriate, the therapeutic benefits of companion animals and the deep personal bonds between patients and their pets should be acknowledged and provided as part of this care.

Measuring Family Satisfaction With Care Delivered in the Intensive Care Unit

BACKGROUND

In our competitive health care environment, measuring the experience of family members of patients in the intensive care unit to ensure that health care providers are meeting families' needs is critical. Surveys from Press Ganey and the Centers for Medicare and Medicaid Services are unable to capture families' satisfaction with care in this setting.

OBJECTIVE

To implement a sustainable measure for family satisfaction in a 12-bed medical and surgical intensive care unit. To assess the feasibility of the selected tool for measuring family satisfaction and to make recommendations that are based on the results.

METHOD

A descriptive survey design using the Family Satisfaction in the Intensive Care Unit 24-item questionnaire to measure satisfaction with care and decision-making.

RESULTS

Forty family members completed the survey. Overall, the mean score for families' satisfaction with care was 72.24% (SD, 14.87%) and the mean score for families' satisfaction with decision-making was 72.03% (SD, 16.61%). Families reported that nurses put them at ease and provided understandable explanations. Collaboration, inclusion of families in clinical discussions, and timely information regarding changes in the patient's condition were the most common points brought up in free-text responses from family members. Written communication, including directions and expectations, would have improved the families' experience.

CONCLUSION

Although patients' family members reported being satisfied with their experience in the intensive care unit, there is room for improvement. Effective communication among the health care team, patients' families, and patients will be targeted for quality improvement initiatives.

Satisfaction with quality of ICU care for patients and families: the euroQ2 project

Background

Families’ perspectives are of great importance in evaluating quality of care in the intensive care unit (ICU). This Danish-Dutch study tested a European adaptation of the “Family Satisfaction in the ICU” (euroFS-ICU). The aim of the study was to examine assessments of satisfaction with care in a large cohort of Danish and Dutch family members and to examine the measurement characteristics of the euroFS-ICU.

Methods

Data were from 11 Danish and 10 Dutch ICUs and included family members of patients admitted to the ICU for 48 hours or more. Surveys were mailed 3 weeks after patient discharge from the ICU. Selected patient characteristics were retrieved from hospital records.

Results

A total of 1077 family members of 920 ICU patients participated. The response rate among family members who were approached was 72%. “Excellent” or “Very good” ratings on all items ranged from 58% to 96%. Items with the highest ratings were concern toward patients, ICU atmosphere, opportunities to be present at the bedside, and ease of getting information. Items with room for improvement were management of patient agitation, emotional support of the family, consistency of information, and inclusion in and support during decision-making processes. Exploratory factor analysis suggested four underlying factors, but confirmatory factor analysis failed to yield a multi-factor model with between-country measurement invariance. A hypothesis that this failure was due to misspecification of causal indicators as reflective indicators was supported by analysis of a factor representing satisfaction with communication, measured with a combination of causal and reflective indicators.

Conclusions

Most family members were moderately or very satisfied with patient care, family care, information and decision-making, but areas with room for improvement were also identified. Psychometric assessments suggest that composite scores constructed from these items as representations of either overall satisfaction or satisfaction with specific sub-domains do not meet rigorous measurement standards. The euroFS-ICU and other similar instruments may benefit from adding reflective indicators.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1826-7) contains supplementary material, which is available to authorized users.

A Typology of ICU Patients and Families from the Clinician Perspective: Toward Improving Communication

This paper presents an exploratory case study of clinician-patient communications in a specific clinical environment. It describes how intensive care unit (ICU) clinicians' technical and social categorizations of patients and families shape the flow of communication in these acute care settings. Drawing on evidence from a year-long ethnographic study of four ICUs, we develop a typology of patients and families as viewed by the clinicians who care for them. Each type, or category, of patient is associated with differing communication strategies, with compliant patients and families engaged in greater depth. In an era that prioritizes patient engagement through communication for all patients, our findings suggest that ICU teams need to develop new strategies for engaging and communicating with not just compliant patients and families, but those who are difficult as well. We discuss innovative methods for developing such strategies.

Sedation versus no sedation: Are there differences in relatives' satisfaction with the Intensive Care Unit? A survey study based on data from a randomised controlled trial

BACKGROUND

Currently there is a trend towards less or no use of sedation of mechanically ventilated patients. Still, little is known about how different sedation strategies affect relatives' satisfaction with the Intensive Care Unit (ICU).

AIM

To explore if there was a difference in relatives' personal reactions and the degree of satisfaction with information, communication, surroundings, care and treatment in the ICU between relatives of patients who receive no sedation compared with relatives of patients receiving sedation during mechanical ventilation in the ICU.

METHOD

A survey study using a questionnaire with 39 questions was distributed to relatives of mechanically ventilated patients, who had been randomised to either sedation with daily wake up or no sedation.

RESULTS

Forty-nine questionnaires were sent out and 36 relatives answered. The response rate was 73%. We found no differences in relatives' personal reactions or in the degree of satisfaction with information, communication, care and treatment in the ICU between relatives of patients in the two groups. Relatives of patients treated with no sedation felt more bothered by disturbances in the surroundings compared with relatives of patients who were sedated (p=0.03).

CONCLUSION

Treating the patient during mechanical ventilation with no sedation does not affect relatives' satisfaction adversely.

Quality of care in the intensive care unit from the perspective of patient's relatives: development and psychometric evaluation of the consumer quality index 'R-ICU'

Background

The quality standards of the Dutch Society of Intensive Care require monitoring of the satisfaction of patient’s relatives with respect to care. Currently, no suitable instrument is available in the Netherlands to measure this. This study describes the development and psychometric evaluation of the questionnaire-based Consumer Quality Index ‘Relatives in Intensive Care Unit’ (CQI ‘R-ICU’). The CQI ‘R-ICU’ measures the perceived quality of care from the perspective of patients’ relatives, and identifies aspects of care that need improvement.

Methods

The CQI ‘R-ICU’ was developed using a mixed method design. Items were based on quality of care aspects from earlier studies and from focus group interviews with patients’ relatives. The time period for the data collection of the psychometric evaluation was from October 2011 until July 2012. Relatives of adult intensive care patients in one university hospital and five general hospitals in the Netherlands were approached to participate. Psychometric evaluation included item analysis, inter-item analysis, and factor analysis.

Results

Twelve aspects were noted as being indicators of quality of care, and were subsequently selected for the questionnaire’s vocabulary. The response rate of patients’ relatives was 81% (n = 455). Quality of care was represented by two clusters, each showing a high reliability: ‘Communication’ (α = .80) and ‘Participation’ (α = .84). Relatives ranked the following aspects for quality of care as most important: no conflicting information, information from doctors and nurses is comprehensive, and health professionals take patients’ relatives seriously. The least important care aspects were: need for contact with peers, nuisance, and contact with a spiritual counsellor. Aspects that needed the most urgent improvement (highest quality improvement scores) were: information about how relatives can contribute to the care of the patient, information about the use of meal-facilities in the hospital, and involvement in decision-making on the medical treatment of the patient.

Conclusions

The CQI ‘R-ICU’ evaluates quality of care from the perspective of relatives of intensive care patients and provides practical information for quality assurance and improvement programs. The development and psychometric evaluation of the CQI ‘R-ICU’ led to a draft questionnaire, sufficient to justify further research into the reliability, validity, and the discriminative power of the questionnaire.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1975-4) contains supplementary material, which is available to authorized users.

Family members' experience of intensive care unit support group: qualitative analysis of intervention

BACKGROUND

Family members of intensive care unit patients develop anxiety, depression and/or symptoms suggestive of risk for post-traumatic stress. Nurse-led support groups have been recommended and used in a variety of settings as a mechanism to help meet family needs and overcome challenges. These groups have been reported to increase the members' understanding of complex medical issues involved in their situations and to be helpful in identifying practical coping mechanisms.

AIM

To investigate the experiences of family members participating in a nurse-social worker led support group in the intensive care unit.

METHOD

Study design: prospective collection of family narratives during support group meetings. A qualitative analysis was done of the narratives of weekly routine nurse-social worker led support group for family members of intensive care unit patients. The meeting contents are documented and related in the nursing notes.

SETTING

level 1 trauma centre, at a university hospital, with 13-bed intensive care unit. During the past 3 years this family support group has been providing routine intervention with the purpose of calming the families of intensive care unit patients during crisis situations by utilizing nurse, social worker and group dynamics.

RESULTS

A qualitative analysis was performed on the content of support group dynamics. The principal themes found were Behavioural, Perceptual, Emotional and Supportive.

CONCLUSIONS

The family support group provides the participants with a 'tool box' of coping mechanisms, which they can choose from in this current unfamiliar crisis event. The group provides a supportive environment, mutuality, a sense of belonging, needs of community, unconditional acceptance and information provision for the participants in the group.

RELEVANCE TO CLINICAL PRACTICE

In order to provide support for several families, nurses can use the family support group intervention as an effective technique in reaching as many families as possible. Narratives from family members during group meetings may be a good information source providing insights for nursing guidance and patient/family education.

The family experiences of in-hospital care questionnaire in severe traumatic brain injury (FECQ-TBI): a validation study

BACKGROUND

Family members are important for support and care of their close relative after severe traumas, and their experiences are vital health care quality indicators. The objective was to describe the development of the Family Experiences of in-hospital Care Questionnaire for family members of patients with severe Traumatic Brain Injury (FECQ-TBI), and to evaluate its psychometric properties and validity.

METHODS

The design of the study is a Norwegian multicentre study inviting 171 family members. The questionnaire developmental process included a literature review, use of an existing instrument (the parent experience of paediatric care questionnaire), focus group with close family members, as well as expert group judgments. Items asking for family care experiences related to acute wards and rehabilitation were included. Several items of the paediatric care questionnaire were removed or the wording of the items was changed to comply with the present purpose. Questions covering experiences with the inpatient rehabilitation period, the discharge phase, the family experiences with hospital facilities, the transfer between departments and the economic needs of the family were added. The developed questionnaire was mailed to the participants. Exploratory factor analyses were used to examine scale structure, in addition to screening for data quality, and analyses of internal consistency and validity.

RESULTS

The questionnaire was returned by 122 (71%) of family members. Principal component analysis extracted six dimensions (eigenvalues > 1.0): acute organization and information (10 items), rehabilitation organization (13 items), rehabilitation information (6 items), discharge (4 items), hospital facilities-patients (4 items) and hospital facilities-family (2 items). Items related to the acute phase were comparable to items in the two dimensions of rehabilitation: organization and information. All six subscales had high Cronbach's alpha coefficients >0.80. The construct validity was confirmed.

CONCLUSION

The FECQ-TBI assesses important aspects of in-hospital care in the acute and rehabilitation phases, as seen from a family perspective. The psychometric properties and the construct validity of the questionnaire were good, hence supporting the use of the FECQ-TBI to assess quality of care in rehabilitation departments.

A family information brochure and dedicated website to improve the ICU experience for patients' relatives: an Italian multicenter before-and-after study

PURPOSE

Good communication between ICU staff and patients' relatives may reduce the occurrence of post-traumatic stress disorder, anxiety or depression, and dissatisfaction with clinicians. An information brochure and website to meet relatives' needs were designed to explain in technical yet simple terms what happens during and after an ICU stay, to legitimize emotions such as fear, apprehension, and suffering, and to improve cooperation with relatives without increasing staff workload. The main outcomes were improved understanding of prognosis and procedures, and decrease of relatives' anxiety, depression, and stress symptoms.

METHODS

In this prospective multicenter before-and-after study, a self-administered questionnaire was used to investigate relatives' understanding of prognosis, treatments, and organ dysfunction, families' satisfaction, and symptoms of anxiety, depression, and post-traumatic stress.

RESULTS

A total of 551 relatives received questionnaires in nine Italian ICUs; 332 (60%) responded, 144 before and 179 after implementation of the brochure and website. Of the 179 relatives who responded after, 131 (73%) stated they had read the brochure and 34 (19%) reported viewing the website. The intervention was associated with increased correct understanding of the prognosis (from 69 to 84%, p = 0.04) and the therapeutic procedures (from 17 to 28%, p = 0.03). Multivariable analysis, together with non-modifiable factors (relative's gender, education level, relationship to patient, and patient status at ICU discharge), showed the intervention to be significantly associated with a lower incidence of post-traumatic stress symptoms (Poisson coefficient = -0.29, 95% CI -0.52/-0.07). The intervention had no effect on the prevalence of symptoms of anxiety and depression.

CONCLUSION

An information brochure and website designed to meet relatives' needs improved family members' comprehension and reduced their prevalence of stress symptoms.

Psychometric assessment of the Family Satisfaction in the Intensive Care Unit questionnaire in the United Kingdom

PURPOSE

To establish the psychometric properties of the Family Satisfaction in the Intensive Care Unit 24-item (FS-ICU-24) questionnaire in the United Kingdom.

MATERIALS AND METHODS

The Family-Reported Experiences Evaluation study recruited family members of patients staying at least 24 hours in 20 participating intensive care units. Questionnaires were evaluated for nonresponse, floor/ceiling effects, redundancy, and construct validity. Internal consistency was evaluated with item-to-own scale correlations and Cronbach α. Confirmatory and exploratory factor analyses were used to explore the underlying structure.

RESULTS

Twelve thousand three hundred forty-six family members of 6380 patients were recruited and 7173 (58%) family members of 4615 patients returned a completed questionnaire. One family member per patient was included in the psychometric assessment. Six items had greater than 10% nonresponse; 1 item had a ceiling effect; and 11 items had potential redundancy. Internal consistency was high (Cronbach α, overall .96; satisfaction with care, .94; satisfaction with decision making, .93). The 2-factor solution was not a good fit. Exploratory factor analysis indicated that satisfaction with decision making encompassed 2 constructs-satisfaction with information and satisfaction with the decision-making process.

CONCLUSIONS

The Family Satisfaction in the Intensive Care Unit 24-item questionnaire demonstrated good psychometric properties in the United Kingdom setting. Construct validity could be improved by use of 3 domains and some scope for further improvement was identified.

What can acute medicine learn from qualitative methods?

PURPOSE OF REVIEW

The contribution of qualitative methods to evidence-based medicine is growing, with qualitative studies increasingly used to examine patient experience and unsafe organizational cultures. The present review considers qualitative research recently conducted on teamwork and organizational culture in the ICU and also other acute domains.

RECENT FINDINGS

Qualitative studies have highlighted the importance of interpersonal and social aspects of healthcare on managing and responding to patient care needs. Clear/consistent communication, compassion, and trust underpin successful patient-physician interactions, with improved patient experiences linked to patient safety and clinical effectiveness across a wide range of measures and outcomes. Across multidisciplinary teams, good communication facilitates shared understanding, decision-making and coordinated action, reducing patient risk in the process.

SUMMARY

Qualitative methods highlight the complex nature of risk management in hospital wards, which is highly contextualized to the demands and resources available, and influenced by multilayered social contexts. In addition to augmenting quantitative research, qualitative investigations enable the investigation of questions on social behaviour that are beyond the scope of quantitative assessment alone. To develop improved patient-centred care, health professionals should therefore consider integrating qualitative procedures into their existing assessments of patient/staff satisfaction.

Differences and similarities between mothers and fathers of premature children: a qualitative study of parents' coping experiences in a neonatal intensive care unit

Background

The aim of this study was to explore and describe the coping experiences of parents to children admitted to a neonatal unit.

Methods

A qualitative research approach was chosen, using in-depth interviews with eight fathers and eight mothers.

Results

The main findings were that parents with previous complicated births had more difficulties in coping compared to those parents with no experience with complications. Coping seemed easier where parents’ opinions were heard regarding their baby’s care and when both parents were present in the neonatal intensive care unit (NICU). The main similarities between mothers and fathers were the reluctance to speak their opinions on childcare, and both experienced a sense of alienation and problems in bonding with the baby. They also needed a limitation on the number of visitors in the NICU. Differences between mothers and fathers were that fathers tried hard to be the strong partner in the relationship, and were more concerned with the mother if she was seriously ill postpartum, while mothers were more concerned for their baby. Mothers’ postpartum period was felt as more stressful if the father was not present, but mothers were also better at welcoming support from the health personnel.

Conclusion

This study highlights the parent’s coping experiences in NICUs. Coping seemed easier where parents’ opinions were heard. Nurses in the NICU should take the former experiences of the parents into consideration when nursing in the NICU and planning for discharge.

Impact of a communication strategy on family satisfaction in the intensive care unit

BACKGROUND

Family satisfaction of critically ill patients has gained increased interest as important indicator to evaluate the quality of care in the intensive care unit (ICU). The family satisfaction in the ICU questionnaire (FS-ICU 24) is a well-established tool to assess satisfaction in such settings. We tested the hypothesis that an intervention, aiming at improved communication between health professionals and patients' next of kin in the ICU improves family satisfaction, as assessed by FS-ICU 24.

METHODS

Using a multicenter before-and-after study design, we evaluated medium-term effectiveness of VALUE, a recently proposed strategy aiming at improved communication. Satisfaction was assessed using the FS-ICU 24 questionnaire. Performance-importance plots were generated in order to identify items highly correlated with overall satisfaction but with low individual score.

RESULTS

A total of 163 completed family questionnaires in the pre-intervention and 118 in the post-intervention period were analyzed. Following the intervention, we observed: (1) a non-significant increase in family satisfaction summary score and sub-scores; (2) no decline in any individual family satisfaction item, and (3) improvement in items with high overall impact on satisfaction but quoted with low degree of satisfaction.

CONCLUSION

No significant improvement in family satisfaction of critically ill adult patients could be found after implementing the VALUE strategy. Whether these results are due to insufficient training of the new strategy or a missing effect of the strategy in our socio-economic environment remains to be shown.

Patient and family satisfaction levels in the intensive care unit after elective cardiac surgery: study protocol for a randomised controlled trial of a preoperative patient education intervention

INTRODUCTION

Patients and their families are understandably anxious about the risk of complications and unfamiliar experiences following cardiac surgery. Providing information about postoperative care in the intensive care unit (ICU) to patients and families may lead to lower anxiety levels, and increased satisfaction with healthcare. The objectives of this study are to evaluate the effectiveness of preoperative patient education provided for patients undergoing elective cardiac surgery.

METHODS AND ANALYSIS

100 patients undergoing elective coronary artery bypass graft, with or without valve replacement surgery, will be recruited into a 2-group, parallel, superiority, double-blinded randomised controlled trial. Participants will be randomised to either preoperative patient education comprising of a video and ICU tour with standard care (intervention) or standard education (control). The primary outcome measures are the satisfaction levels of patients and family members with ICU care and decision-making in the ICU. The secondary outcome measures are patient anxiety and depression levels before and after surgery.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Joint Chinese University of Hong Kong-New Territories East Cluster Clinical Research Ethics Committee (reference number CREC 2015.308). The findings will be presented at conferences and published in peer-reviewed journals. Study participants will receive a 1-page plain language summary of results.

TRIAL REGISTRATION NUMBER

ChiCTR-IOR-15006971.

Intensive Care Unit death and factors influencing family satisfaction of Intensive Care Unit care

INTRODUCTION

Family satisfaction of Intensive Care Unit (FS-ICU) care is believed to be associated with ICU survival and ICU outcomes. A review of literature was done to determine factors influencing FS-ICU care in ICU deaths.

RESULTS

Factors that positively influenced FS-ICU care were (a) communication: Honesty, accuracy, active listening, emphatic statements, consistency, and clarity; (b) family support: Respect, compassion, courtesy, considering family needs and wishes, and emotional and spiritual support; (c) family meetings: Meaningful explanation and frequency of meetings; (d) decision-making: Shared decision-making; (e) end of life care support: Support during foregoing life-sustaining interventions and staggered withdrawal of life support; (f) ICU environment: Flexibility of visiting hours and safe hospital environment; and (g) other factors: Control of pain and physical symptoms, palliative care consultation, and family-centered care. Factors that negatively influenced FS-ICU care were (a) communication: Incomplete information and unable to interpret information provided; (b) family support: Lack of emotional and spiritual support; (c) family meetings: Conflicts and short family meetings; (d) end of life care support: Resuscitation at end of life, mechanical ventilation on day of death, ICU death of an elderly, prolonged use of life-sustaining treatment, and unfamiliar technology; and (e) ICU environment: Restrictive visitation policies and families denied access to see the dying loved ones.

CONCLUSION

Families of the patients admitted to ICU value respect, compassion, empathy, communication, involvement in decision-making, pain and symptom relief, avoiding futile medical interventions, and dignified end of life care.

Comfort and patient-centred care without excessive sedation: the eCASH concept

We propose an integrated and adaptable approach to improve patient care and clinical outcomes through analgesia and light sedation, initiated early during an episode of critical illness and as a priority of care. This strategy, which may be regarded as an evolution of the Pain, Agitation and Delirium guidelines, is conveyed in the mnemonic eCASH—early Comfort using Analgesia, minimal Sedatives and maximal Humane care. eCASH aims to establish optimal patient comfort with minimal sedation as the default presumption for intensive care unit (ICU) patients in the absence of recognised medical requirements for deeper sedation. Effective pain relief is the first priority for implementation of eCASH: we advocate flexible multimodal analgesia designed to minimise use of opioids. Sedation is secondary to pain relief and where possible should be based on agents that can be titrated to a prespecified target level that is subject to regular review and adjustment; routine use of benzodiazepines should be minimised. From the outset, the objective of sedation strategy is to eliminate the use of sedatives at the earliest medically justifiable opportunity. Effective analgesia and minimal sedation contribute to the larger aims of eCASH by facilitating promotion of sleep, early mobilization strategies and improved communication of patients with staff and relatives, all of which may be expected to assist rehabilitation and avoid isolation, confusion and possible long-term psychological complications of an ICU stay. eCASH represents a new paradigm for patient-centred care in the ICU. Some organizational challenges to the implementation of eCASH are identified.

Family-Reported Experiences Evaluation (FREE) study: a mixed-methods study to evaluate families’ satisfaction with adult critical care services in the NHS

Background

To improve care it is necessary to feed back experiences of those receiving care. Of patients admitted to intensive care units (ICUs), approximately one-quarter die, and few survivors recollect their experiences, so family members have a vital role. The most widely validated tool to seek their views is the Family Satisfaction in the Intensive Care Unit questionnaire (FS-ICU).

Objectives

To test face and content validity and comprehensibility of the FS-ICU (phase 1). To establish internal consistency, construct validity and reliability of the FS-ICU; to describe family satisfaction and explore how it varies by family member, patient, unit/hospital and other contextual factors and by country; and to model approaches to sampling for future use in quality improvement (phase 2).

Design

Mixed methods: qualitative study (phase 1) and cohort study (phase 2).

Setting

NHS ICUs (n = 2, phase 1;n = 20, phase 2).

Participants

Health-care professionals, ex-patients, family members of ICU patients (n = 41, phase 1). Family members of ICU patients (n = 12,303, phase 2).

Interventions

None.

Main outcome measures

Key themes regarding each item of the 24-item FS-ICU (FS-ICU-24) (phase 1). Overall family satisfaction and domain scores of the FS-ICU-24 (phase 2).

Results

In phase 1, face validity, content validity and comprehensibility were good. Adaptation to the UK required only minor edits. In phase 2, one to four family members were recruited for 60.6% of 10,530 patients (staying in ICU for 24 hours or more). Of 12,303 family members, 7173 (58.3%) completed the questionnaire. Psychometric assessment of the questionnaire established high internal consistency and criterion validity. Exploratory factor analysis indicated new domains:satisfaction with care,satisfaction with informationandsatisfaction with the decision-making process. All scores were high with skewed distributions towards more positive scores. For family members of ICU survivors, factors associated with increased/decreased satisfaction were age, ethnicity, relationship to patient, and visit frequency, and patient factors were acute severity of illness and invasive ventilation. For family members of ICU non-survivors, average satisfaction was higher but no family member factors were associated with increased/decreased satisfaction; patient factors were age, acute severity of illness and duration of stay. Neither ICU/hospital factors nor seasonality were associated. Funnel plots confirmed significant variation in family satisfaction across ICUs. Adjusting for family member and patient characteristics reduced variation, resulting in fewer ICUs identified as potential outliers. Simulations suggested that family satisfaction surveys using short recruitment windows can produce relatively unbiased estimates of average family satisfaction.

Conclusions

The Family-Reported Experiences Evaluation study has provided a UK-adapted, psychometrically valid questionnaire for overall family satisfaction and three domains. The large sample size allowed for robust multilevel multivariable modelling of factors associated with family satisfaction to inform important adjustment of any future evaluation.

Limitations

Responses to three free-text questions indicate the questionnaire may not be sensitive to all aspects of family satisfaction.

Future work

Reservations remain about the current questionnaire. While formal analysis of the free-text questions did not form part of this proposal, brief analysis suggested considerable scope for improvement of the FS-ICU-24.

Study registration

Current Controlled Trials ISRCTN47363549.

Funding details

The National Institute for Health Research Health Services and Delivery Research programme.

Critical care: Are we customer friendly?

Objective:

Assessing and enhancing family satisfaction are imperative for the provision of comprehensive intensive care. There is a paucity of Indian data exploring family's perception of Intensive Care Unit (ICU) patients. We wanted to explore family satisfaction and whether it differed in families of patients admitted under intensivists and nonintensivists in our semi-open ICU.

Methodology:

We surveyed family members of 200 consecutive patients, between March and September 2009 who were in ICU for >3 days. An internationally validated family satisfaction survey was adapted and was administered to a family member, on day 4 of the patient's stay. The survey consisted of 15 questions in five categories - patient care, medical counseling, staff interaction, visiting hours, and facilities and was set to a Likert scale of 1–4. Mean, median, and proportions were computed to describe answers for each question and category.

Results:

A total of 515 patients were admitted during the study period, of which 200 patients stayed in the ICU >3 days. One family member each of the 200 patients completed the survey with 100% response rate. Families reported the greatest satisfaction with patient care (94.5%) and least satisfaction with visiting hours (60.5%). Chi-square tests performed for each of the five categories revealed no significant difference between satisfaction scores of intensivists and nonintensivists' patients.

Conclusion:

Family members of ICU patients were satisfied with current care and communication, irrespective of whether they were admitted under intensivists or nonintensivists. Family members preferred open visiting hours policy than a time limited one.

Questionnaires on Family Satisfaction in the Adult ICU: A Systematic Review Including Psychometric Properties

OBJECTIVES

To perform a systematic review of the literature to determine which questionnaires are currently available to measure family satisfaction with care on the ICU and to provide an overview of their quality by evaluating their psychometric properties.

DATA SOURCES

We searched PubMed, Embase, The Cochrane Library, Web of Science, PsycINFO, and CINAHL from inception to October 30, 2013.

STUDY SELECTION

Experimental and observational research articles reporting on questionnaires on family satisfaction and/or needs in the ICU were included. Two reviewers determined eligibility.

DATA EXTRACTION

Design, application mode, language, and the number of studies of the tools were registered. With this information, the tools were globally categorized according to validity and reliability: level I (well-established quality), II (approaching well-established quality), III (promising quality), or IV (unconfirmed quality). The quality of the highest level (I) tools was assessed by further examination of the psychometric properties and sample size of the studies.

DATA SYNTHESIS

The search detected 3,655 references, from which 135 articles were included. We found 27 different tools that assessed overall or circumscribed aspects of family satisfaction with ICU care. Only four questionnaires were categorized as level I: the Critical Care Family Needs Inventory, the Society of Critical Care Medicine Family Needs Assessment, the Critical Care Family Satisfaction Survey, and the Family Satisfaction in the Intensive Care Unit. Studies on these questionnaires were of good sample size (n ≥ 100) and showed adequate data on face/content validity and internal consistency. Studies on the Critical Care Family Needs Inventory, the Family Satisfaction in the Intensive Care Unit also contained sufficient data on inter-rater/test-retest reliability, responsiveness, and feasibility. In general, data on measures of central tendency and sensitivity to change were scarce.

CONCLUSIONS

Of all the questionnaires found, the Critical Care Family Needs Inventory and the Family Satisfaction in the Intensive Care Unit were the most reliable and valid in relation to their psychometric properties. However, a universal "best questionnaire" is indefinable because it depends on the specific goal, context, and population used in the inquiry.

Patient and family/friend satisfaction in a sample of Jordanian Critical Care Units

AIM

The aim of the study was to assess the validity of family members/friends as proxies by comparing perceptions of satisfaction with care and decision making between critically ill patients and their family/friends.

DESIGN

A comparative, descriptive cross-sectional study.

SETTING

Seven Critical Care Units across four public and military hospitals in the centre and southern regions of Jordan.

METHODS

A modified version of the Family Satisfaction-ICU (FS-ICU) questionnaire was distributed to Critical Care Unit (CCU) patients before hospital discharge. In addition, up to two family members/close friends were also asked to complete the questionnaire.

RESULTS

A total of 213 patients (response rate 72%) and 246 family members/friends (response rate 79%) completed and returned the questionnaire. Although the majority of family members/friends and patients were satisfied with overall care, patients were generally significantly less satisfied (mean (SD) care subscale 75.6 (17.8) and 70.9 (17.3), respectively, (p=0.005). When individual items were examined, significant differences in nursing care (family/friends 80.1 (20.7) versus patient 75.9 (22.2), p=0.038) and inclusion in decision making (family/friends 53.9 (33.2) versus patient 62.0 (34.2), p=0.010) were found.

CONCLUSION

The study showed a degree of congruence between patients and their family members/friends in relation to their satisfaction with the CCU experience. Thus, views of family/friends may serve as a proxy in assessing care and decision making processes of critically ill patients.

RELEVANCE TO CLINICAL PRACTICE

Appropriate training of the critical care team and provision of strategies to address the concerns of patients' families are needed to improve overall patient satisfaction.

The satisfaction of families in the care of their loved ones in CCUs in Lebanon

BACKGROUND

The needs of family members vary among cultures and hospitals. Often, these needs remain unmet increasing their stress and anxiety and decreasing their satisfaction with care, which may negatively impact the quality of patient care.

AIMS

To assess the satisfaction of families with the care of their loved ones in critical care units (CCUs) in a large university medical centre in Lebanon and to assess the predictors of satisfaction.

METHODS

A cross-sectional descriptive design was conducted using the Critical Care Family Satisfaction Survey (CCFSS). The participants were 123 adult relatives or significant others of patients cared for in both adult and paediatric intensive care units for at least 3 days.

RESULTS

The CCFSS showed acceptable internal reliability and construct validity in a Lebanese population. In general, families were satisfied with the care their loved ones received in the CCUs, and the least satisfaction was in the area of 'comfort' and the highest was in 'assurance'. Younger family members with more education were less satisfied with care and Christian families expressed less satisfaction with informational needs compared with Muslim families. Families of children in the paediatric CCU expressed least satisfaction with care. Gender, residency, relationship to patient, unit, prior experience in a CCU and diagnosis had no effect on satisfaction scores.

CONCLUSIONS

Assessment of family satisfaction in different cultures is important as each culture has specific needs that are essential to decipher.

IMPLICATIONS FOR PRACTICE

Patient satisfaction leads to improved quality of care; thus, it behoves nurses to meet the needs of families from different cultures to help them cope and increase their satisfaction, which leads to improve patient outcomes.

Planning intensive care unit design using computer simulation modeling: optimizing integration of clinical, operational, and architectural requirements

Nurses have increasingly been regarded as critical members of the planning team as architects recognize their knowledge and value. But the nurses' role as knowledge experts can be expanded to leading efforts to integrate the clinical, operational, and architectural expertise through simulation modeling. Simulation modeling allows for the optimal merge of multifactorial data to understand the current state of the intensive care unit and predict future states. Nurses can champion the simulation modeling process and reap the benefits of a cost-effective way to test new designs, processes, staffing models, and future programming trends prior to implementation. Simulation modeling is an evidence-based planning approach, a standard, for integrating the sciences with real client data, to offer solutions for improving patient care.

Intensive care patient and family satisfaction

Purpose

– The purpose of this paper is to measure family member satisfaction with the care provided in an Australian private intensive care unit (ICU) at two time points separated by two years. The study was part of a quality improvement process for ICU, and was designed with reference to the revised Australian Commission on Safety and Quality in Health care.

Design/methodology/approach

– This prospective study involved family members of patients admitted in ICU in February 2011 and February 2013. All patients admitted to during the study month were eligible. Questionnaire addressed staff competence, treatment of family, communication, environment and overall satisfaction, using a Likert scale. There was one free text question. The first survey was done by handing the survey package to the next of kin at the time of discharge while the second involved mailing a survey package within a week of discharge from ICU. Quantitative analysis was based on ten Likert items and qualitative analysis based on the free text question.

Findings

– The response rate was 53 percent (54/102) in 2013 (mailed) compared to 44 percent (44/100) in 2011 (hand delivered). The results from second (2013) survey showed statistically significant improvement in satisfaction associated with nursing and medical competency. Other areas with improvement were the relative’s waiting room and visiting hours. The area lacking improvement was ease of finding ICU the hospital. It confirmed that families were satisfied with the care provided and highlighted areas for improvement. The results indicated high satisfaction overall, especially with the hospital staff competency and the overall care quality their relative received. Though most responses also indicated satisfaction with communication and support services, these areas did not perform as well.

Originality/value

– This study provided a simple and effective mechanism to monitor consumer satisfaction with ICU.

Care and caring in the intensive care unit: Family members' distress and perceptions about staff skills, communication, and emotional support

PURPOSE

Family members of intensive care unit (ICU) patients are sometimes highly distressed and report lower satisfaction with communication and emotional support from staff. Within a study of emotional responses to traumatic stress, associations between family distress and satisfaction with aspects of ICU care were investigated.

MATERIALS AND METHODS

In 29 family members of trauma patients who stayed in an ICU, we assessed symptoms of depression and posttraumatic stress disorder (PTSD) during ICU care. Later, family members rated staff communication, support, and skills and their overall satisfaction with ICU care.

RESULTS

Ratings of staff competence and skills were significantly higher than ratings of frequency of communication, information needs being met, and support. Frequency of communication and information needs being met were strongly related to ratings of support (rs = .75-.77) and staff skills (rs = .77-.85), and aspects of satisfaction and communication showed negative relationships with symptoms of depression (rs = -.31 to -.55) and PTSD (rs = -.17 to -.43).

CONCLUSIONS

Although satisfaction was fairly high, family member distress was negatively associated with several satisfaction variables. Increased understanding of the effects of traumatic stress on family members may help staff improve communication and increase satisfaction of highly distressed family members.

Open access in the critical care environment

Open access has become an important topic in critical care over the last 3 years. In the past, critical care had restricted access and set visitation guidelines to protect patients. This article provides a review of the literature related to open access in the critical care environment, including the impact on patients, families, and health care providers. The ultimate goal is to provide care centered on patients and families and to create a healing environment to ensure safe passage of patients through their hospital stays. This outcome could lead to increased patient/family satisfaction.

Quality of dying in the ICU: is it worse for patients admitted from the hospital ward compared to those admitted from the emergency department?

OBJECTIVE

Although most intensive care unit (ICU) admissions originate in the emergency department (ED), a substantial number of admissions arrive from hospital wards. Patients transferred from the hospital ward often share clinical characteristics with those admitted from the ED, but family expectations may differ. An understanding of the impact of ICU admission source on family perceptions of end-of-life care may help improve patient and family outcomes by identifying those at risk for poor outcomes.

DESIGN AND SETTING

This was a cohort study of patients with chronic illness and acute respiratory failure requiring mechanical ventilation who died after admission to an ICU in any of the 14 participating hospitals in the Seattle-Tacoma area between 2003 and 2008 (n = 1,500).

MEASUREMENTS

Using regression models adjusted for hospital site and patient-, nurse- and family-level characteristics, we examined associations between ICU admission source (hospital ward vs. ED) and (1) family ratings of satisfaction with ICU care; (2) family and nurse ratings of quality of dying; (3) chart-based indicators of palliative care.

MAIN RESULTS

Admission from the hospital ward was associated with lower family ratings of quality of dying [β -0.90, 95% confidence interval (CI) -1.54, -0.26, p = 0.006] and satisfaction (total score β -3.97, 95% CI -7.89, -0.05, p = 0.047; satisfaction with care domain score β -5.40, 95% CI -9.44, -1.36, p = 0.009). Nurses did not report differences in quality of dying. Patients from hospital wards were less likely to have family conferences [odds ratio (OR) 0.68, 95% CI 0.52, 0.88, p = 0.004] or discussion of prognosis in the first 72 h after ICU admission (OR 0.72, 95% CI 0.56, 0.91, p = 0.007) but were more likely to receive spiritual care (OR 1.48, 95% CI 1.14, 1.93, p = 0.003) or have life support withdrawn (OR 1.38, 95% CI 1.04, 1.82, p = 0.025).

CONCLUSION

Admission from the hospital ward is associated with family perceptions of a lower quality of dying and less satisfaction with ICU care. Differences in receipt of palliative care suggest that family of patients from the hospital ward receive less communication. Nurse ratings of quality of dying did not significantly differ by ICU admission source, suggesting dissimilarities between family and nurse perspectives. This study identifies a patient population at risk for poor quality palliative and end-of-life care. Future studies are needed to identify interventions to improve care for patients who deteriorate on the wards following hospital admission.

Half of the family members of critically ill patients experience excessive daytime sleepiness

BACKGROUND

Sleepiness and fatigue are commonly reported by family members of intensive care unit (ICU) patients. Sleep deprivation may result in cognitive deficits. Sleep deprivation and cognitive blunting have not been quantitatively assessed in this population. We sought to determine the proportion of family members of ICU patients that experience excessive daytime sleepiness, sleep-associated functional impairment, and cognitive blunting.

METHODS

Multicenter, cross-sectional survey of family members of patients admitted to ICUs at the University of Maryland Medical Center, Johns Hopkins University Hospital, and Christiana Hospital. Family members of ICU patients were evaluated using the Epworth Sleepiness Scale, a validated survey assessing sleepiness in everyday situations (normal, less than 10); the Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10), a questionnaire quantifying the impact of sleepiness on daily activities (normal, at least 17.9); and psychomotor vigilance testing, a test of cognitive function, in relation to sleep deprivation (normal mean reaction time less than 500 ms).

RESULTS

A total of 225 family members were assessed. Of these, 50.2 % (113/225) had Epworth scores consistent with excessive daytime sleepiness. Those with sleepiness experienced greater impairment in performing daily activities by FOSQ-10 (15.6 ± 3.0 vs 17.4 ± 2.2, p < 0.001). Cognitive blunting was found in 13.3 % (30/225) of family members and 15.1 % (14/93) of surrogate decision-makers. Similar rates of cognitive blunting as reported by mean reaction time of at least 500 ms were found among family members whether or not they reported sleepiness (15.0 % (17/113) vs. 11.6 % (13/112), p = 0.45).

CONCLUSIONS

Half of the family members of ICU patients suffer from excessive daytime sleepiness. This sleepiness is associated with functional impairment, but not cognitive blunting.

Benefit of using a "bundled" consent for intensive care unit procedures as part of an early family meeting

PURPOSE

Relatives of patients in the intensive care unit (ICU) are often dissatisfied with family-physician communication. Our prospective preintervention and postintervention study tested the hypothesis that introducing this informed consent process would improve family satisfaction with the ICU process of care.

MATERIALS AND METHODS

We developed a consent form that included an introductory explanation of the main ICU interventions and a description of 8 common procedures in a surgical ICU. We administered it early in the ICU course during a scheduled family meeting. The study was a prospective preintervention and postintervention design.

RESULTS

The "Family Satisfaction in the Intensive Care Unit" (FS-ICU) score was higher in the intervention than in the control group (95.4±4 vs 78.2±22, P<.001). The nursing perception of satisfaction with care was also higher in the intervention group (95.8±13 vs 71.9±28, P<.001).

CONCLUSION

A bundled informed consent resulted in higher family satisfaction with the process of care in ICU.

Identifying meaningful outcome measures for the intensive care unit

Despite important progress in measuring the safety of health care delivery in a variety of health care settings, a comprehensive set of metrics for benchmarking is still lacking, especially for patient outcomes. Even in high-risk settings where similar procedures are performed daily, such as hospital intensive care units (ICUs), these measures largely do not exist. Yet we cannot compare safety or quality across institutions or regions, nor can we track whether safety is improving over time. To a large extent, ICU outcome measures deemed valid, important, and preventable by clinicians are unavailable, and abstracting clinical data from the medical record is excessively burdensome. Even if a set of outcomes garnered consensus, ensuring adequate risk adjustment to facilitate fair comparisons across institutions presents another challenge. This study reports on a consensus process to build 5 outcome measures for broad use to evaluate the quality of ICU care and inform quality improvement efforts.