Susan M. Roberti, RN, MS, DNP and Joyce J. Fitzpatrick, RN, MBA, PhD +Author Affiliations 1. Susan M.

Roberti is a clinical assistant professor at Lienhard School of Nursing, Pace University in Pleasantville, New York, and is founder and president of SMR Enterprises in New York, New York.Joyce J. Fitzpatrick is the Elizabeth Brooks Ford Professor of Nursing at Frances Payne Bolton School of Nursing, Case Western Reserve University in Cleveland, Ohio 1. Corresponding author: Joyce J. Fitzpatrick, RN, MBA, PHD, FAAN, Elizabeth Brooks Ford Professor of Nursing, Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106 (e-mail:[email protected]). PRIME POINTS In critical care environments, patient satisfaction is often difficult to obtain; family satisfaction with care can be used as a substitute for patient satisfaction.

Assessing Family Satisfaction With Care of Critically Ill Patients: A Pilot Study

The assessment tool used in this pilot study can assist nurses and other professionals to improve practice and increase family satisfaction.

This article has been designated for CE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives: 1. Describe the challenges associated with assessing patient satisfaction in critical care environments 2. Identify key factors that family members are likely to consider when assessing their level of satisfaction with the overall patient care provided 3. Discuss relevant nursing implications for delivery and improvement of care that resulted from this study In todays society, developing a competitive edge has become crucial for survival in any industry. In health care, patient satisfaction has become one of the most important and challenging competitive elements. Health care professionals are expected to provide both high quality of care and exceed customers expectations while being cost conscious and efficient. Satisfaction is typically measured by satisfaction surveys that patients complete about their recent hospital experience. However, assessing patient satisfaction in critical care environments becomes complicated. Often patients are not making decisions related to their own care because of their severity of illness and level of consciousness.1 Patients are

typically too sick to determine the level of satisfaction with care provided or may not even remember their critical care experience, which makes patient satisfaction surveys inadequate. As a result, family members are often the ones who determine satisfaction with care provided, as well as with the overall critical care experience. Thus, satisfaction may be measured by the perception of family members who determine if the patient received high-quality care regardless of clinical outcomes. The challenge for health care providers is to determine what family members consider when assessing their level of satisfaction with the overall care provided. A patients family is an integral part of the care of the patient. Family provides support to the patient and can thus be instrumental in the patients recovery. Harvey2 described how the crisis of a critical illness affects both the patient and the family, identifying family satisfaction as a surrogate for patient satisfaction in critical care. Only a few studies, however, have described family satisfaction with care of patients who are in a critical care setting.36 The purpose of the present pilot study was to build on this previous research by assessing the level of family satisfaction with overall care of critically ill patients and identifying areas for future research. Review of Literature Since 2001, a number of studies have been done in which researchers have investigated family satisfaction with care. Most studies have included use of the Critical Care Family Needs Inventory (CCFNI), which is focused specifically on the needs of the family members while the patient is being cared for in the critical care unit. The CCFNI was used in several studies with large samples that included family members from different cultures.3,7,8 This instrument had been developed and validated by Johnson and colleagues.6 In the studies with this instrument, researchers identified the following predictors of family satisfaction: patient to nurse ratio of 3 or less; information provided by physicians; information provided to the family; knowledge of the role of each caregiver; involvement of their usual doctor; desired/allowed time ratio.3 The CCFNI also was used in a prospective randomized trial in 34 French intensive care units to determine if those family members who received a structured family information leaflet would have higher satisfaction scores. Those who understood the diagnosis, prognosis, and treatment had higher satisfaction levels. Although satisfaction did not differ significantly between the leaflet and the control groups, family members who had good comprehension and received a leaflet had significantly higher median satisfaction scores than did family members who did not.7 Previous research on family satisfaction with care is summarized in Table 1. These studies are presented chronologically, with the study purpose, sample, and instrument identified. Major findings and recommendations by the researchers also are presented. Summary of previous research presented chronologically As indicated in Table 1, several researchers have developed their own questionnaires to measure family satisfaction with care.4,5,9,11 These studies were conducted among family members of various groups of patients, but all included the same goal of assessing some aspect of family satisfaction.

Heyland and colleagues4,5 were particularly interested in the area of communication and decision making, and thus their instrument includes an emphasis on those dimensions. They found a positive relationship between satisfaction with overall care and satisfaction with decision making regarding care (r=0.64). In addition, the measurement of overall satisfaction with care was reliable (r=0.85). The researchers concluded that the instrument had acceptable reliability and validity for use with next of kin of critically ill patients.4 In a follow-up study,5 Heyland and colleagues evaluated family satisfaction with care provided to critically ill patients and their families in 6 intensive care units across Canada. In this study,5 both family members of survivors and family members of nonsurvivors were included. Of the 624 respondents, 54% considered their satisfaction with care to be excellent, and 41% considered their satisfaction with decision making to be excellent. The researchers concluded that most family members were satisfied with the overall care provided in the intensive care unit. However, opportunities for improvement were present in physician-patient communication and in the manner in which health care providers interact with patients and their families.5 Fox-Wasylyshyn et al11 focused their study specifically on patients family members perceptions of how well nurses were fulfilling their needs. The study was conducted with 29 family members from a 19-bed intensive care unit. The researchers found the expectations that family members held regarding nurses roles with families were not different from their perceptions of what nurses actually did. In addition, family members were more satisfied with care when nurses performance either met or exceeded their expectations. Another approach was that designed by McDonagh and colleagues,9 who studied family satisfaction as related to the amount of time family members spoke in clinical conferences. They conducted a cross-sectional study in 4 hospitals with 214 family members from 51 different families and 36 different physicians who led the family conferences. Based on their analysis of conference videotapes, the researchers suggested that allowing family members more opportunity to speak during conferences could improve family satisfaction. More recently, Stricker and colleagues12,13 have developed and evaluated an instrument focused on family satisfaction with intensive care, but with particular focus on satisfaction with information and decision making. This team of researchers also has assessed the potential use of this instrument with family members from different cultures and demonstrated that the instrument had high reliability and validity across cultures.12 They also reported overall high satisfaction with care; higher severity of illness was associated with higher satisfaction as were a higher nurse to patient ratio and written admission and discharge instructions.13 On the basis of the increasing value placed on family satisfaction with care of critically ill patients and the concern that existing instruments did not measure overall satisfaction with care, Wasser and colleagues1,10 developed and validated the Critical Care Family Satisfaction Survey (CCFSS), which consists of 20 items. The instrument was developed to serve as a proxy for patient satisfaction, and it measures overall satisfaction with care. The researchers assessed the psychometric qualities of the instrument with 2494 family members of patients admitted to 10 critical care units in a 3-year period and found high reliability and validity for their instrument. Wasser and colleagues considered it important to include all dimensions of care when evaluating family members satisfaction with care provided in critical care units.

The CCFSS was considered the most inclusive survey and thus was selected for use in the present study. Previous research had been focused on specific aspects of family satisfaction with care rather than on families satisfaction with overall care of critically ill patients. Methods Sample After approval was received from the institutional review board, this pilot study was conducted in a 10-bed medical surgical intensive care unit (MSICU) and a 14-bed telemetry/intermediate care unit in a community hospital in the Northeast. A convenience sample of 31 participants, family members of patients in the MSICU and the telemetry/intermediate care unit, was used. Any family member of a surviving patient who was transferred out or discharged from the MSICU or the telemetry/intermediate care unit who was 18 years of age or older and consented to participate could be included in the study. Surveys were limited to 1 family member per patient. The family was asked to designate a spokesperson to fill out the survey when multiple family members were available. The exclusion criteria were family members with a language barrier, which was determined on the basis of the unit secretarys assessment and ability to communicate effectively with the family member in English. Family members of nonsurvivors were excluded to avoid unnecessary burden. Upon receiving an order to transfer or discharge a patient, the unit secretary provided a family member with a packet consisting of an informed consent document, survey, and envelope. The unit secretary was selected to distribute the packets for optimal consistency and because the unit secretaries were not providers of patient care. Locked drop boxes were available in the MSICU, the telemetry/intermediate care unit, and the family lounge so that surveys could be returned confidentially. Participation was voluntary. Instrument The CCFSS, developed by Wasser and colleagues1,10 was used to measure family satisfaction with overall care. Wasser and colleagues evaluated the psychometrics of the CCFSS, and delineated the scoring for both total and subscale scores. Content and construct validity were examined and the 2001 study1 provided support that the CCFSS was reliable and valid; the Cronbach alpha was 0.93 for the 5-factor model. The survey yields the following 5 subscales: assurance (the need to feel hope for a desired outcome), information (the need for consistent, realistic, and timely information), proximity (the need for personal contact and to be physically and emotionally near the patient), support (the need for resources, support systems, and ventilation), and comfort (the need for personal comfort). The survey contains the following background questions: your age (referring to participant), number of days your loved one is/was in the critical care unit, relationship of person filling out the survey to the patient, and why the family member was in the critical care unit. Twenty items are related to satisfaction with care; each item is ranked by

the family member on a scale with responses from 1 to 5 (1=very dissatisfied and 5=very satisfied). Scoring for the 20 items was completed by the researchers and based on the following scale:

Excellent or completely satisfied=100 (highest possible score) Very good or very satisfied=75 Good or mostly satisfied=50 Poor or slightly dissatisfied=25 Very poor or very dissatisfied=0 (lowest possible score).

Permission to use the tool was granted by Wasser, and the following information was provided to calculate the subscales: for assurance, add up the scores for items 3, 4, 7, and 19 and divide by 4; for information, add up the scores for items 2, 6, 10, 12, and 20 and divide by 5; for proximity, add up the scores for items 5, 15, and 18 and divide by 3; for support, add up the scores for items 1, 9, 11, 13, 14, and 16 and divide by 6; and for comfort, add up the scores for items 8 and 17 and divide by 2. Statistical Analyses Fifty-one surveys were distributed, with an overall response rate of 61% and a total of 31 participants. In the MSICU, 19 surveys were distributed and 13 were returned, for a response rate of 68%. In the telemetry/intermediate care unit, 32 surveys were distributed and 18 were returned, for a 56% response rate. Of the 31 participants, 42% were from the MSICU and 58% were from the telemetry/intermediate care unit. The instructions to the participants were to fill out one survey per patient. Most of the participants were 35 to 59 years of age; the second largest age group of participants was 60 years of age or older. Most participants were the patients wife; the next highest category was the patients daughter. Results Related to the CCFSS The reliability of the CCFSS in this pilot study was assessed; the Cronbach alpha for the total scale was 0.96. The Cronbach alphas for the subscales ranged from 0.74 (assurance subscale) to 0.92 (information subscale; Table 2). Reliability statistics for subscales The CCFSS mean score for the MSICU was 94; for the telemetry/intermediate care unit, the CCFSS mean score was 94.17. An analysis was done to determine the frequency and percentage of participants responses for each question in the survey. Question 11 (Quality of care given to my family member) had the most responses of very satisfied (n=27, 87%) and the highest mean score (4.87) of all questions. Question 3 (waiting time for results of tests and radiographs) had the

fewest responses for very satisfied (n=19, 61%) and the lowest mean score (4.48;Table 3). In examining the 5 subscales, support had the highest mean score (4.74; SD, 0.43) and comfort had the lowest mean score (4.62; SD, 0.60; Table 4). Descriptive statistics for scores on subscales (N = 31) Qualitative data were assessed in 3 questions, which were part of the CCFSS and on the original instrument. Frequencies of responses were noted for each of the 3 questions. The results from the first question (Why is your family member in the critical care unit?) included 6 responses from family members of patients in the MSICU (eg, patients with pneumonia, respiratory arrest/failure, new onset atrial fibrillation, rectal bleeding) and 9 responses from family members of patients in the telemetry/intermediate care unit (eg, patients with pneumonia, chest pain, heart problems, heart attack, kidney failure). Results for the second question (What else would you like us to know so we can take better care of our patients and their families?) included 4 responses for each unit. For this second question, 2 positive comments from family members of patients in the MSICU talked about how professional, helpful, and caring the doctors and nurses were and what a wonderful facility it was. Other responses included a suggestion that a bed extension be available for tall patients and a negative comment about a nurse being rude and uncaring toward a patients parents. In the telemetry/intermediate care unit, 1 positive comment was made about the care and the clear answers to all questions that were received. One suggestion was that staff obtain a contact person and phone number for a family member so that staff can call with questions/discussions. Two negative comments were focused on the incompetence and poor beside manner of 3 staff members (none of whom were staff on the unit and none of whom were nursing staff ). Results for the third question (Please feel free to name any individuals you feel are worthy of special recognition) included 6 responses from the MSICU and 11 responses from the telemetry/intermediate care unit. In the MSICU, 3 physicians, 13 nurses, 1 nursing assistant, 4 respiratory therapists, the respiratory department, and 2 staff from the magnetic resonance imaging department were named for positive recognition. Two nurses were mentioned 3 times, and 2 other nurses were mentioned twice positively. One nurse received 2 comments, 1 of which was very positive and the other comment very negative. In the telemetry/intermediate care unit, 4 physicians (1 from the emergency department), 5 nurses (1 from the emergency department), 2 technicians, and 1 unit secretary were named for positive recognition. Discussion The overall results of this pilot study indicate that family members of critically ill patients in the MSICU and the telemetry/intermediate care units were generally satisfied with care provided. In addition to the favorable results based on the quantitative data, most of the responses in the qualitative data also were positive. Also, some specific suggestions were made for improvements in the overall care that could be provided. Limitations

The results of this pilot study are limited by the use of a convenience sample, the small sample size, the single site for data collection, the limited time period, and the small community hospital setting. In addition, the results do not account for patient acuity or telemetry/intermediate care patients that may have been admitted to the MSICU because of lack of room availability. The survey does not take into account patients who remained in one of the units because an appropriate bed for transfer was not available. Implications for Delivery and Improvement of Care The results of this pilot study are relevant to the design and implementation of care delivery for clinical nurse managers, clinical educators, and hospital administrators. Waiting time for results of tests and radiographs had the overall lowest score, and noise level in the critical care unit had the second overall lowest score. For the MSICU, noise level was the lowest score and for the telemetry/intermediate care unit, waiting time for results of tests and radiographs was the lowest score. On the unit level, nurse managers and staff can focus on waiting time for results based on the most frequent tests performed and identified delays and/or communication gaps in reporting those results. Conducting a root cause analysis for waiting time for results and noise level can also provide useful information that allows a corrective action plan to be implemented. Raising awareness can sensitize staff to the problematic areas so they can communicate more effectively with patients and their families in regard to waiting for important test results and interpretations of radiographs. Hospital administrators need to be involved in identification of these problems, because the problems identified may be greater than on the unit level and might affect other areas within the hospital. In addition, administrators may be able to offer solutions or suggestions that unit level managers cannot. For example, if laboratory turnaround time is delayed because of an inadequate workforce, hospital administrators may be able to reallocate staffing or work flow. The process for radiography requires an official interpretation of the images by a radiologist, communication of the results to a physician, then either communication of the results to the nurse or in some cases communication directly to the patient and/or the patients family. In critical care environments, multiple tests and procedures are typically being conducted on several patients, challenging health care providers to prioritize their time, which may bump communication of information to a low level. One area that can be corrected through education and intervention in regard to waiting time for results is to explain before the procedure what the process is for determining test results, which staff member is responsible for communicating those results, and what is the expected time frame for receiving those results. Hospital staff may consider the use of a patient/family communication board or log, such as a communication corner, where patients and/or family members can document questions or concerns to address with the physician or other appropriate health care providers. This proactive approach to communication raises awareness of staff about what concerns need to be addressed in a timely manner based on what the patient and/or family member determines to be a high priority. Hospitals

may also consider part of the requirements for documentation of test results to include providing that information to the patient and/or family members. Noise level in any environment that operates 24 hours a day, 7 days a week is challenging. Staff members often need to be reminded that although they are in the hospital to work, the patients are there to rest and recover. Providing a quiet environment is as important as providing high-quality care to patients, especially for certain diagnoses in which reduced stimulation is necessary. Some suggestions for health care providers are as follows: closing doors to patients rooms when appropriate, using pagers rather than an overhead paging system, requiring pagers to be set on vibrate rather than audible alerts, assessing equipment that requires maintenance, such as squeaky wheels, dimming lights during night time hours to serve as a reminder for staff to keep voices down, implementing a decibel alarm system that flashes when noise level exceeds the desired limit, making sure that doors to the unit have devices to prevent banging or slamming shut, providing appropriate space for staff to take their breaks in and for conferences to be conducted in, requiring that doors to patients rooms be closed during physician rounds and/or peak activity times for the unit, and implementing a sound system that plays soothing music for patients and their family members to listen to rather than letting them focus on noise levels. In assessing satisfaction with care, patients families often assess the environment. Staff, managers, and administrators should recognize that the environment of care is part of the overall satisfaction. The comfort subscale addresses the environment and the results revealed the lowest scores overall. Two questions are addressed: cleanliness and appearance of the waiting room and peacefulness of the waiting room. In the pilot study hospital, one waiting area called the MSICU Family Lounge is designated for use by families of patients from both the MSICU and the telemetry/intermediate care unit. This room is also shared by families of patients having surgery. The room has no windows and poor signage, which may have contributed to the lower scores. The design of the unit/hospital may or may not allow for a dedicated waiting area or lounge for the telemetry/intermediate care unit; however, the designated purpose of the room needs to be clear and consistent. Alternative solutions for waiting family members, such as a beeper system as used in other businesses, could be investigated to help alleviate this problem. If space is an issue, the beeper system would provide more flexibility and comfort for family members to know they can be reached regardless of where in the hospital they are waiting. Recommendations for Future Research The findings of this pilot study provide a foundation for future benchmarking and opportunities for improvement in family satisfaction of critically ill patients. Replication of this pilot study with a larger sample size could provide useful information and better comparisons between like units. Serial studies at the same organization can also provide ongoing opportunities to evaluate if scores in a particular area are improving or declining. Conclusion

In summary, the results of this pilot study indicate that family members of critically ill patients in this setting are generally satisfied with care. In todays competitive health care market, hospitals must strive to increase customer satisfaction. Sharing this information with all members of the health care team can provide specific details regarding the expectations of family members. Proper education of staff and provision of strategies to address the concerns of patients families can significantly improve overall customer satisfaction scores. Such changes will ultimately foster a more rewarding experience for both patients and their families, creating an environment of comfort, peace, and healing.