ORIGINAL ARTICLE | https://doi.org/10.5005/jp-journals-10071-24104 |
Can We Satisfy Family in Intensive Care Unit? A Tunisian Experience
1–4University of Tunis El Manar, University of Medicine of Tunis, Ben Arous Regional Hospital, Tunis, Tunisia
Corresponding Author: Ines Fathallah, University of Tunis El Manar, University of Medicine of Tunis, Ben Arous Regional Hospital, Tunis, Tunisia, e-mail: ines822004@yahoo.fr
How to cite this article: Fathallah I, Drira H, Habacha S, Kouraichi N. Can We Satisfy Family in Intensive Care Unit? A Tunisian Experience. Indian J Crit Care Med 2022;26(2):185–191.
Source of support: Nil
Conflict of interest: None
ABSTRACT
Background: Communication improvement and family satisfaction in intensive care unit (ICU) are the main indicators of care quality. Our study aims were to evaluate family satisfaction in our intensive care and identify factors influencing the satisfaction level.
Materials and methods: We performed a descriptive prospective study in the ICU of Ben Arous régional hospital conducted between October 2016 and June 2018. We included parents of patients hospitalized for more than 48 hours, with available contact details and they agreed to reply to the questionnaire.
Results: One hundred and twelve family representatives were included. Ten (9%) were illiterate and 40 (36%) had a primary level education. Noninvasive ventilation and hemodialysis were, respectively, used in 53 and 9.8% of cases. Thirteen patients had sequelae at their hospital discharge. The median satisfaction score was 133.5 (120; 145.7). Ninety-five (85%) relatives were always satisfied with cleanliness of the unit. The medical and paramedical staff availability was appreciated as excellent, respectively, by 65 (56%) and 66 (59%) family members. The information provided by doctors and paramedical staff was considered very clear by 75 (65%) and 65 (58%) parents, respectively. The medical secret was respected by medical (n = 107) and paramedical (n = 105) staffs in most cases. Patient management was considered excellent by 90 (80%) parents. The level of satisfaction was lower when the parent interviewed was illiterate (p = 0.04) or had a primary-level education (p = 0.012), with hemodialysis resort (p = 0.011) and with the presence of sequelae at hospital discharge (p = 0.017).
Conclusion: Family members were satisfied with the unit environment, the communication, the healthcare management, and the patient care. Low education level, hemodialysis use, and sequelae at hospital discharge influence negatively the satisfaction.
Keywords: Critically ill, Experience, Family satisfaction, Healthcare.
BACKGROUND
The satisfaction of patients’ families is increasingly considered as an essential concept in care quality evaluation procedures.
In the intensive care environment, the impossibility of communication with patients has made the involvement of family representatives, both in medical information and in therapeutic decision-making, necessary in the care quality policy improvement.1–3 In addition, extreme stress experienced by families highlights the importance of a well-thought-out communication strategy and the role of psychological support.
Our study aimed to
Evaluate the satisfaction of the families of patients hospitalized in intensive care.
Identify factors influencing the satisfaction level.
MATERIALS AND METHODS
The descriptive, prospective single-center study was carried out in the medical intensive care unit of the regional hospital of Ben Arous over a period of 20 months (from October 2016 to June 2018).
During this period, the doctor/patient ratio was 1.6:1.
The paramedical staff of the service was divided into four teams, each team was made up of three nurses and a caregiver.
A hospitality manual, in two versions Arabic and French, explaining the department operation and specifying physicians’ contact information and schedule of visits, was issued to families on admission.
Family visits were allowed daily through a gallery with a total visiting time of 2 hours/day (from 1 to 3 pm). The doctor in charge of the patient communicates every day with the family representative.
Study Population
The population in our study included family representatives of patients hospitalized for a period of time greater than or equal to 48 hours, having had visits during the journey.
The representatives were adults appointed by the family members on admission. They can be an ascendant or a descendant. For lack, the representative can be patient’s distant relative or a friend who visits him (or her) during his stay and communicates with the medical and paramedical team. Family representatives who refused to answer the survey and who could not be reached after three phone calls were all excluded. Phone calls were made weekly and at different times of the day.
Data Collection
For each patient included in the study, a data sheet was completed.
The first part of data was collected from medical records. The second part, relating to the satisfaction survey, was completed through phone calls with family representatives.
Phone interviews were spread over a period of 2 months. They were performed by three doctors who were not a part of our healthcare team.
Verbal consents were obtained over the phone calls.
Satisfaction Assessment Score
Satisfaction was assessed using a survey (Appendix) that was developed by our team and validated by the hospital’s quality control service with reference to the family satisfaction in the intensive care unit (FS-ICU)4,5 and critical care family needs inventory (CCFNI).6,7
Satisfaction score was calculated from the 32 items of the survey. Items were multiple-choice questions: excellent, very good, good, average, and poor satisfaction. For each item, scores were coded as follows: the lowest value denotes extreme dissatisfaction (value = 1) and the highest value denotes extreme satisfaction (value = 5). The value of the satisfaction score was obtained by calculating the sum of all items in the survey. The score ranged from 32 to 160 (32 being the state of extreme dissatisfaction and 160 being the state of extreme satisfaction).
Data Entry and Analysis
Statistical processing of data was divided into two components: the first one was descriptive and the second was analytic.
To study the relationships that may exist between the different variables and the satisfaction score, several tests were used:
Student’s t-tests for independent series and analysis of variance (ANOVA) were used to compare groups and subgroups in case of normal distribution.
Mann–Whitney and Kruskall–Wallis U tests were used for non-Gaussian distribution.
Pearson’s Chi-square test was used to compare qualitative variables.
The significance level retained for the study was 0.05.
RESULTS
One hundred twelve families were included in our study with a participation rate of 81%. Ninety family representatives (80%) were first-degree relatives.
Ten (9%) were illiterate and 40 (36%) had a primary school level.
The median age of our patients was 56 years (36; 69). The median simplified acute physiology score II (SAPS) II8 at admission was 29 (20; 43). Nineteen patients (17%) had a history of intensive care hospitalization. Noninvasive ventilation and mechanical ventilation were used, respectively, for 59 (53%) and 58 (52%) patients. Eleven patients (9.8) required hemodialysis during their stay.
The median hospital stay in the intensive care unit was 8 days (5; 16). Thirteen patients (12%) had sequelae on discharge. The overall mortality rate was 26%.
Assessment of Family Satisfaction
The median satisfaction score was 133.5 (120; 145.75) with a minimum score of 86 and a maximum score of 156.
No complaints regarding the duration and times of the visits were reported. Ninety-five (85%) relatives were always satisfied with cleanliness of the unit.
Availability of medical and paramedical staff was judged to be excellent by 62 (56%) and 66 (59%) family representatives, respectively.
Information provided by doctors and paramedics was considered very clear by 72 (65%) and 65 (58%) family representatives, respectively.
The medical secret was respected by medical (n = 107) and paramedical (n = 105) staff in most cases.
Psychological support was deemed to be always present by the medical and paramedical staff by 62 (55%) and 55 (49%) family representatives, respectively.
Only 25 representatives (22%) claimed lack of medical devices and treatments.
The therapeutic management was judged to be excellent by 80% of the representatives (n = 90).
Nursing care was rated as excellent by 61% of representatives (n = 68). Only one family representative considered the quality of care to be poor.
Continuity of care was rated excellent by 70 family representatives (63%).
Study of Factors Influencing the Satisfaction Level
Use of dialysis (p = 0.011), presence of sequelae at patient’s discharge (p = 0.017), and being illiterate at the evaluation of intellectual level of the family representative (p = 0.040) were factors that negatively influenced families’ satisfaction.
Use of noninvasive ventilation (NIV) (p = 0.013) and primary intellectual level of the family’s representative (p = 0.012) were factors that positively influenced families’ satisfaction (Table 1).
| Median score | |||
|---|---|---|---|
| Yes | No | p | |
| Intellectual level | 121.5 (112.25; 131.75) | 0.040 | |
| Illiterate | 137 (121.5; 146) | ||
| Intellectual level | 141.5 (128.25; 148) | 0.012 | |
| Primary | 127 (117.25; 144) | ||
| History of hospitalization in ICU | 139 (116; 146) | 133 (121; 145.5) | 0.356 |
| Mechanical ventilation | 131 (119; 144) | 139 (122; 148) | 0.280 |
| Noninvasive ventilation | 141 (125; 147) | 127 (115; 142) | 0.013 |
| Dialysis | 118 (116; 126) | 139 (122; 146) | 0.011 |
| Death | 128 (122; 145) | 136 (119.5; 146) | 0.655 |
| Sequelae at discharge | 131 (119; 145) | 146 (126.5; 151.5) | 0.017 |
DISCUSSION
Despite sociocultural differences (expectations of families would be different) and in particular economic conditions (nurse/patient and doctor/patient ratios), the satisfaction level in our population was comparable to that described in European and American studies.9–11
In literature, several studies have shown that families want free access to patients hospitalized in intensive care units.6,12,13 Other studies have shown that bed visits were inconvenient for patients and could disrupt the work of healthcare providers.14
In our study, bed visits were not allowed in majority of the cases, but this was not a source of dissatisfaction for the families.
Communication is one of the cornerstones in satisfactory assessment. The importance of communication in the medical field has been demonstrated by many studies.15–18 In our population, satisfaction with the quality of interviews and information provided by the medical staff was deemed satisfactory. This can be explained by the importance given to communication with patients’ families in our department. But a good deal of work remains to be done for further improvement.
Psychological support is also a key element of the relationship between caretakers and patients. The training of our team on communication, in particular ability to listen, and families’ involvement in staff meetings had also improved families’ satisfaction in intensive care departments.19–22
In our study, the use of NIV was associated with higher satisfaction. This element can be explained by the application of a protocol for starting and monitoring NIV sessions with the almost constant presence of nursing staff. On the contrary, interviews are carried out with families by doctors with distribution of brochures to explain the different care procedures to them. This attitude was considered reassuring by families.
In our study, the satisfaction score was lower when family representatives were intellectually illiterate. Families with a low level of education would have more difficulty to accept stressful situations and assimilate explanations, even with simplified medical terms. It was easier for families with a higher education level to understand the provided information.
The level of satisfaction among the families of patients with sequelae at discharge was lower. The lack of a structure for rehabilitation of patients with sequelae could explain dissatisfaction of these families in our study, especially since most of our patients were discharged at home.
In view of the heavy nursing care required by patients with sequelae at discharge, the creation of post-acute rehabilitation units had been recommended by the Hospital Organization Guidelines in France.23
The prospective randomized study RECOVER of Walsh had shown that rehabilitation after resuscitation in specialized centers increased the patient’s satisfaction rate.24
CONCLUSION
Regardless of the limits of our study, it could be concluded that the family representatives were satisfied with communication with our healthcare team and with therapeutic management. Illiteracy, use of hemodialysis, and presence of sequelae at discharge negatively influenced the satisfaction level.
REFERENCES
1. Gerstel E, Engelberg RA, Koepsell T, Curtis JR. Duration of withdrawal of life support in the intensive care unit and association with family satisfaction. Am J Respir Crit Care Med 2008;178(8):798–804. DOI: 10.1164/rccm.200711-1617OC.
2. Jordan PJ. Visitors in the intensive care unit. S Afr Med J 2014;30(1):4. DOI: 10.7196/sajcc.196.
3. Azoulay É, Cattaneo I, Ferrand É, Pochard F. «L’Information au patient de Réanimation et à ses proches: le point de vue de la SRLF». Réanimation 2001;10(6):571–581. DOI: 10.1016/S1164-6756(01)00169-4.
4. Wall RJ, Engelberg RA, Downey L, Heyland DK, Curtis JR. Refinement, scoring, and validation of the family satisfaction in the intensive care unit survey. Crit Care Med 2007;35(1):271–279. DOI: 10.1097/01.CCM.0000251122.15053.50.
5. Heyland DK, Rocker GM, Dodek PM, Kutsogiannis DJ, Konopad E, Cook DJ, et al. Family satisfaction with care in the intensive care unit: results of a multiple center study. Crit Care Med 2002;30(7):1413–1418. DOI: 10.1097/00003246-200207000-00002.
6. Molter NC. Needs of relatives of critically ill patients: a descriptive study. Heart Lung 1979;8(2):332–339. PMID: 253712.
7. Johnson D, Wilson M, Cavanaugh B, Bryden C, Gudmundson D, Moodley O. Measuring the ability to meet family needs in an intensive care unit. Crit Care Med 1998;26(2):266–271. DOI: 10.1097/00003246-199802000-00023.
8. Le Gall JR, Neumann A, Hemery F, Bleriot JP, Fulgencio JP, Garrigues B, et al. Mortality prediction using SAPS II: an update for French intensive care units. Crit Care 2005;9(6):R645–R652. DOI: 10.1186/cc3821.
9. Stricker KH, Niemann S, Bugnon S, Wurz J, Rohrer O, Rothen HU. Family satisfaction in the intensive care unit: cross-cultural adaptation of a questionnaire. J Crit Care 2007;22(3):204–211. DOI: 10.1016/j.jcrc.2006.12.008.
10. Schwarzkopf D, Behrend S, Skupin H, Westermann I, Riedemann NC, Pfeifer R, et al. Family satisfaction in the intensive care unit: a quantitative and qualitative analysis. Intensive Care Med 2013;39(6):1071–1079. DOI: 10.1007/s00134-013-2862-7.
11. Osborn TR, Curtis JR, Nielsen EL, Back AL, Shannon SE, Engelberg RA. Identifying elements of ICU care that families report as important but unsatisfactory. Chest 2012;142(5):1185–1192. DOI: 10.1378/chest.11-3277.
12. Gajic O, Afessa B, Hanson AC, Krpata T, Yilmaz M, Mohamed SF, et al. Effect of 24-hour mandatory versus on-demand critical care specialist presence on quality of care and family and provider satisfaction in the intensive care unit of a teaching hospital. Crit Care Med 2008;36(1):36–44. DOI: 10.1097/01.CCM.0000297887.84347.85.
13. Molter NC. Families are not visitors in the critical care unit. Dimens Crit Care Nurs 1994;13(1):2–3. DOI: 10.1097/00003465-199401000-00001.
14. Mosleh S, Aljaafreh M, Lee AJ. Patient and family/friend satisfaction in a sample of Jordanian critical care units. Intensive Crit Care Nurs 2015;31(6):366–374. DOI: 10.1016/j.iccn.2015.04.004.
15. Fins JJ, Solomon MZ. Communication in intensive care settings: the challenge of futility disputes. Crit Care Med 2001;29(1):10–15. DOI: 10.1097/00003246-200102001-00003.
16. Cohen S, Sprung C, Sjokvist P, Lippert A, Ricou B, Baras M, et al. Communication of end-of-life decisions in European intensive care units. Intensive Care Med 2005;31(9):1215–1221. DOI: 10.1007/s00134-005-2742-x.
17. Azoulay E, Pochard F. Communication with family members of patients dying in the intensive care unit. Curr Opin Crit Care 2003;9(6):545–550. DOI: 10.1097/00075198-200312000-00014.
18. Lilly CM, Demeo DL, Sonna LA, Haley KJ, Massaro AF, Wallace RF, et al. An intensive communication intervention for the critically ill. Am J Med 2000;109(6):469–475. DOI: 10.1016/s0002-9343(00)00524-6.
19. Curtis JR, Treece PD, Nielsen EL, Gold J, Ciechanowski PS, Shannon SE, et al. Randomized trial of communication facilitators to reduce family distress and intensity of end-of-life care. Am J Respir Crit Care Med 2016;193(2):154–162. DOI: 10.1164/rccm.201505-0900OC.
20. Schaefer KG, Block SD. Physician communication with families in the ICU: evidence-based strategies for improvement. Curr Opin Crit Care 2009;15(6):569–577. DOI: 10.1097/MCC.0b013e328332f524.
21. Adams A, Mannix T, Harrington A. Nurses’ communication with families in the intensive care unit – a literature review. Nurs Crit Care 2017;22(2):70–80. DOI: 10.1111/nicc.12141.
22. Adams JA, Anderson RA, Docherty SL, Tulsky JA, Steinhauser KE, Bailey DE. Nursing strategies to support family members of ICU patients at high risk of dying. Heart Lung 2014;43(5):406–415. DOI: 10.1016/j.hrtlng.2014.02.001.
23. Berard E, Chougrani M, Tasseau F. An evaluation of a post-acute rehabilitation unit after five years of operations. Ann Phys Rehabil Med 2010;53(8):457–473. DOI: 10.1016/j.rehab.2010.07.003.
24. Walsh TS, Salisbury LG, Merriweather JL, Boyd JA, Griffith DM, Huby G, et al. Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the recover randomized clinical trial. JAMA Intern Med 2015;175(6):901–910. DOI: 10.1001/jamainternmed.2015.0822.
APPENDIX
SATISFACTION OF FAMILIES’ REPRESENTATIVES OF INTENSIVE CARE PATIENTS
Patient
Name and surname
File number
Admission date
Age
Sex
Marital status
History of ICU hospitalization
Degree of autonomy before admission (WHO scale)
Reason of admission
Diagnosis retained
State of consciousness on admission
Level of severity on admission (SAPS II score)
Use of sedation during the stay
Use of mechanical ventilation
1. Yes
2. No
Use of NIV
1. Yes
2. No
Length of stay
Output mode
Possible sequelae on discharge
Family’s Representative
Age
Sex
Relationship
Level of study
1. Illiterate
2. Primary
3. Secondary
4. University
Profession
Satisfaction Questionnaire
General Framework
1. Is there a waiting room?
Yes
No
2. Have you been allowed to visit your relative in bed?
Always
Often
Rarely
Never
3. Do you feel comfortable during the visit?
Always
Often
Rarely
Never
4. Are you satisfied with the hygiene level in the department?
Always
Often
Rarely
Never
Communication with the Staff
1. Have you received the brochure explaining how the service works?
Yes
No
2. Level of understanding of the brochure: is it?
Excellent
Very good
Good
Medium
Bad
3. Quality of communication with Doctors and Paramedics
| Availability | Doctors | Paramedics | |
|---|---|---|---|
| Excellent | |||
| Very good | |||
| Good | |||
| Medium | |||
| Bad | |||
| Quality of given information | Doctors | Paramedics | |
| Very clear | |||
| Clear | |||
| Clear enough | |||
| Not clear enough | |||
| Incomprehensible | |||
| Do you feel that information was discordant | |||
| Always | |||
| Quitter frequently | |||
| Often | |||
| Rarely | |||
| Never | |||
| Do you think that you were having all information regarding your patient’s state of health? | |||
| Always | |||
| Quite frequently | |||
| Often | |||
| Rarely | |||
| Never | |||
| How do you judge the staff’s attitude regarding your demands? | |||
| Excellent | |||
| Very good | |||
| Good | |||
| Medium | |||
| Bad | |||
| Did you face an abuse? | |||
| Always | |||
| Quite frequently | |||
| Often | |||
| Rarely | |||
| Never | |||
| Did you find the staff interested with your psychological state? | |||
| Always | |||
| Quite frequently | |||
| Often | |||
| Rarely | |||
| Never | |||
| Do you think that the staff respected the medical confidentiality? | Doctors | Paramedics | |
| Always | |||
| Quite frequently | |||
| Often | |||
| Rarely | |||
| Never |
Nursing and Treatment
1. Do you judge that nursing and treatment were at the maximum level
*In the material plane (missing material/rely on explorations or private care/drugs purchase...)
Always
Quite frequently
Often
Rarely
Never
*In the human plane
Always
Quite frequently
Often
Rarely
Never
2. How do you find the management of
*Pain
Excellent
Very good
Good
Medium
Bad
*Anxiety/agitation
Excellent
Very good
Good
Medium
Bad
*Breathing difficulties
Excellent
Very good
Good
Medium
Bad
3. You judge the respect for your relative’s privacy:
Excellent
Very good
Good
Medium
Bad
4. You judge the respect of the person of your relative:
Excellent
Very good
Good
Medium
Bad
5. Do you think that we have to work on some points to improve quality of care?
Yes
No
Therapeutic Decisions
1. Are you involved in the making of therapeutic decisions?
Always
Quite frequently
Often
Rarely
Never
2. You judge that time allowed to reflection is
Very sufficient
Sufficient
Moderately sufficient
Insufficient
3. Do you feel that you can control care provided to your relative?
Always
Quite frequently
Often
Rarely
Never
4. Do you want to leave the decision to doctors?
Yes
No
5. Do you have any proposals to improve the quality of care and communication?
________________________
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