Qualitative analysis of an intensive care unit family satisfaction survey

[Expectations of relatives of critically ill patients regarding medical information. Qualitative research study]

OBJECTIVE

To determine and analyse the expectations, needs and experiences of relatives of critically ill patients as regards medical information and the level of their understanding. To find keys for improving communication and to draw up best practices in clinical information.

MATERIAL AND METHODS

Qualitative research study through semi-structured interviews carried out in a polyvalent adult intensive care unit (ICU) in a University Hospital.

PARTICIPANTS

relatives of patients who were admitted to the ICU and who were discharged alive from the Unit. Ten interviews were performed taking into account diversification variables such as, type of family relationship with patients, patient age, length of ICU stay, origin, and location at the time of the interview.

RESULTS

The results of the analysis of 10 interviews focused on: the subjective position of the family in the ICU (the agonizing wait), what the ICU represents for the family (surveillance and monitoring of a situation between life and death), perceived care (complete delegation of care), and medical information (what and how they expect and what and how they receive it), as much in the first information (sincerity, hope, delicacy) as in the successive.

CONCLUSIONS

There is divergence between what families expect and what they get as regards medical information. To know the expectations of the families will help to provide higher quality care and more humane treatment in the ICU.

Recognizing, naming, and measuring a family intensive care unit syndrome

Most major decisions in the intensive care unit (ICU) regarding goals of care are shared by clinicians and someone other than the patient. Multicenter clinical trials focusing on improved communication between clinicians and these surrogate decision makers have not reported consistently improved outcomes. We suggest that acquired maladaptive reasoning may contribute importantly to failure of the intervention strategies tested to date. Surrogate decision makers often suffer significant psychological morbidity in the form of stress, anxiety, depression, and post-traumatic stress disorder. Family members in the ICU also suffer cognitive blunting and sleep deprivation. Their decision-making abilities are eroded by anticipatory grief and cognitive biases, while personal and family conflicts further impact their decision making. We propose recognizing a family ICU syndrome to describe the morbidity and associated decision-making impairment experienced by many family members of patients with acute critical illness (in the ICU) and chronic critical illness (in the long-term, acute care hospital). Research rigorously using models of compromised decision making may help elucidate both mechanisms of impairment and targets for intervention. Better quantifying compromised decision making and its relationship to poor outcomes will allow us to formulate and advance useful techniques. The use of decision aids and improving ICU design may provide benefit now and in the near future. In measuring interventions targeting cognitive barriers, clinically significant outcomes, such as time to decision, should be considered. Statistical approaches, such as survival models and rank statistic testing, will increase our power to detect differences in our interventions.

Assessment of satisfaction with care among family members of survivors in a neuroscience intensive care unit

Many prior nursing studies regarding family members specifically of neuroscience intensive care unit (neuro-ICU) patients have focused on identifying their primary needs. A concept related to identifying these needs and assessing whether they have been met is determining whether families explicitly report satisfaction with the care that both they and their loved ones have received. The objective of this study was to explore family satisfaction with care in an academic neuro-ICU and compare results with concurrent data from the same hospital's medical ICU (MICU). Over 38 days, we administered the Family Satisfaction-ICU instrument to neuro-ICU and MICU patients' families at the time of ICU discharge. Those whose loved ones passed away during ICU admission were excluded. When asked about the respect and compassion that they received from staff, 76.3% (95% CI [66.5, 86.1]) of neuro-ICU families were completely satisfied, as opposed to 92.7% in the MICU (95% CI [84.4, 101.0], p = .04). Respondents were less likely to be completely satisfied with the courtesy of staff if they reported participation in zero formal family meeting. Less than 60% of neuro-ICU families were completely satisfied by (1) frequency of physician communication, (2) inclusion and (3) support during decision making, and (4) control over the care of their loved ones. Parents of patients were more likely than other relatives to feel very included and supported in the decision-making process. Future studies may focus on evaluating strategies for neuro-ICU nurses and physicians to provide better decision-making support and to implement more frequent family meetings even for those patients who may not seem medically or socially complicated to the team. Determining satisfaction with care for those families whose loved ones passed away during their neuro-ICU admission is another potential avenue for future investigation.

Process of implementing collaborative care and its impacts on the provision of care and rehabilitation services to patients with a moderate or severe traumatic brain injury

Objective

The introduction of new services in a rehabilitation center is a unique opportunity to introduce a new model of care and services between two institutions. A hospital and a rehabilitation center experienced a clinical management model inspired by an American approach – collaborative care. The purpose of this study was to describe the implementation of this approach and to provide a perception of the quality of care and services provided to patients with moderate or severe traumatic brain injury and to their caregivers.

Materials and methods

In this qualitative study, individual semistructured interviews were conducted with patients and their caregivers in the hospital and rehabilitation center where the patients were treated. Individual semistructured interviews were conducted with administrators, and two focus groups were held with clinicians before and after the implementation.

Results and conclusion

Ten days’ waiting time were saved with the collaborative approach. Implementing the collaborative care approach has been found to have several benefits, including improved communication, coordination of services between institutions, and better preparation, awareness, and involvement of patients and their families. Administrators, clinicians, patients, and caregivers expressed their opinions on the organization of care and services, the needs and expectations of patients and their caregivers, their participation in terms of roles and responsibilities, their perception of continuity of care, their satisfaction with the care process, and their suggestions for improvements.

Psychometric evaluation of a modified version of the family satisfaction in the ICU survey in parents/caregivers of critically ill children*

OBJECTIVES

The Family Satisfaction in the Intensive Care Unit 24 (FS-ICU 24) survey consists of two domains (overall care and medical decision-making) and was validated only for family members of adult patients in the ICU. The purpose of this study was to evaluate the internal consistency and construct validity of the FS-ICU 24 survey modified for parents/caregivers of pediatric patients (Pediatric Family Satisfaction in the Intensive Care Unit 24 [pFS-ICU 24]) by comparing it to McPherson's PICU satisfaction survey, in a similar racial/ethnic population as the original Family Satisfaction in the Intensive Care Unit validation studies (English-speaking Caucasian adults). We hypothesized that the pFS-ICU 24 would be psychometrically sound to assess satisfaction of parents/caregivers with critically ill children.

DESIGN

A prospective survey examination of the pFS-ICU 24 was performed (1/2011-12/2011). Participants completed the pFS-ICU 24 and McPherson's survey with the order of administration alternated with each consecutive participant to control for order effects (nonrandomized). Cronbach's alphas (α) were calculated to examine internal consistency reliability, and Pearson correlations were calculated to examine construct validity.

SETTING

University-affiliated, children's hospital, cardiothoracic ICU.

SUBJECTS

English-speaking Caucasian parents/caregivers of children less than 18 years old admitted to the ICU (on hospital day 3 or 4) were approached to participate if they were at the bedside for greater than or equal to 2 days.

MEASUREMENTS AND MAIN RESULTS

Fifty parents/caregivers completed the surveys (mean age ± SD = 36.2±9.6 yr; 56% mothers). The α for the pFS-ICU 24 was 0.95 and 0.92 for McPherson's survey. Overall, responses for the pFS-ICU 24 and McPherson's survey were significantly correlated (r = 0.73; p < 0.01). The average overall pFS-ICU 24 satisfaction score was 92.6 ± 8.3. The average pFS-ICU 24 satisfaction with care domain and medical decision-making domain scores were 93.3 ± 8.8 and 91.2 ± 8.9, respectively.

CONCLUSIONS

The pFS-ICU 24 is a psychometrically sound measure of satisfaction with care and medical decision-making of parents/caregivers with children in the ICU.

Visiting Policies in the Adult Intensive Care Units in the Netherlands: Survey among ICU Directors

Introduction. Admission to the ICU is a significant event for patients and their families and is often accompanied by stress, anxiety and depression. Literature shows that implementation of “unrestricted visiting policy” (UP) can potentially alleviate psychologically distressing elements of ICU admission. Methods. A web-based questionnaire was sent to all ICU’s concerning three main topics: general ICU information, detailed visiting policy information, and rationale for the chosen policy. Results. 87.1% of ICU’s retain “restricted visiting policies” (RVP; ≤five visiting hours per day). Knowledge about the current literature was overall 60.8%. There is an UP in two academic hospitals and a “partly restricted policy” (PRP; >5 visiting hours per day but <24) in two academic, two large teaching and five general hospitals. Mean permissible duration in ICU’s with a RVP was min versus min in the PRP. Conclusion. Nine out of ten ICU’s still have a restricted visiting policy. The main reasons cited for a restricted visiting policy were potential interference with the daily clinical routine and privacy. A better knowledge of the current literature in combination with infrastructural changes might improve patients’ outcome by reducing stress for the patient and its family.

Partnering with family members to improve the intensive care unit experience

Family members play an important and varied role in a patient's health care experience, ranging from emotional support to surrogate health care decision making. The family role can be substantial in the intensive care unit setting, as the patients rely upon family members to make health care decisions for them. The core components of patient- and family-centered care include information sharing, a welcoming environment, respect for individual values and needs, comfort and support, and providing a helpful framework for developing a productive partnership with family members. Involving family members in daily operations and providing services that make it easier for family members to participate in the care process result in the best possible care for their loved one. Including the family perspective in quality improvement initiatives better ensures that any changes made will result in better care for future patients and family members.

[Communication in intensive care medicine]

Communication plays a crucial role in the intensive care unit. Posttraumatic stress syndromes develop in a significant number of patients and their relatives after being in an intensive care unit. The syndromes may persist for several years. Regular open and empathic communication with patients and family members reduces the frequency and severity of the disease. Among the physicians and nurses in the intensive care unit, there is a high prevalence of burnout syndrome. The precipitating factors are mostly conflicts within the working staff, work overload and end-of-life situations. Working team communication reduces the rate of exhaustion syndromes. Rounds of discussions among the work groups are the basis for a healthy team structure. Inadequate communication, e.g., during emergencies or shift change, endangers the safety of patients and in the worst case, results in treatment mistakes. Measures for improved communication in the intensive care unit should always be implemented.