A cross-sectional study assessing family satisfaction in the intensive care environment in Bahrain: opportunities for improvement

Introduction

In recent years, quality of care has become an issue of the highest priority in health care services, including aspects relating to the quality of life,^1,2 care processes,³ and resource use.⁴ The ICU is the part of the hospital where seriously ill patients are cared for by specially trained staff. Along with them, family members also contribute to caring by providing support and resources to critically ill patients. Quality of care in the ICU includes the satisfaction of family members, who often take on responsibility for medical decisions on behalf of their ill person.⁵ Indeed, the critical care environment may place a prolonged burden on patients^6,7 as well as their family members.⁸ It has been reported that the levels of satisfaction are somewhat lower in various aspects, particularly communication, emotional support, and the hospital environment.⁹

The healthcare strategy for one country cannot automatically be adopted by other countries. Hence, nationwide interest has developed regarding research to assess the needs of ICU patients, aiming to improve the quality of care in the ICU. However, patients in the ICU are often unable to communicate with the healthcare team during decision-making processes because of their illness or the effects of treatments, such as sedation and/or mechanical ventilation.^10,11 In this regard, family members are not only visitors in the ICU, but, along with patients, they are also confronted with the complex process of ICU care, including a technical environment and frequent changeovers in staff.^12,13 Physicians, nurses, and other health care providers in the ICU may find themselves caring not only for the physical needs of patients but also the psychological needs of the families.^14,15 For these reasons, the experience of family members attending the ICU has been considered a major aspect while developing various tools for the assessment of family needs and satisfaction with ICU care.¹⁶ However, family satisfaction with care is a complex issue, and no gold standard definition is currently available to assess this concept.

Although the first report of families’ opinions was published in the 1970s,¹⁷ systematic assessment of family satisfaction with intensive care was only possible after 2001, when the first measurable tool was developed by Wasser et al.,¹⁸ Subsequently, other tools were also developed, and validated. These tools are mostly questionnaires, but those are advocated internationally as means to improve patient care.

Assessing the satisfaction of family members with the care and support they receive helps to improve the quality of care provided to families of ICU patients.¹⁹ Furthermore, improved communication with families of ICU patients has been shown to aid decision-making, resulting in reduced ICU stays, withdrawal of life-sustaining interventions when found appropriate,^20,21 as well as increased overall psychological well-being.²² The American Society for Critical Care Medicine guidelines recommended that training in “good communication skills should become a standard component of medical education for all ICU caregivers” and further suggested that empathic communication, skilful discussion of prognosis, and effective shared decision-making reflected the quality of care provided in the ICU.²³

Although there are reports showing that family members are generally highly satisfied,^12,24 several areas have been identified as opportunities for improvement, such as communication with ICU care providers, participation in patient care and decision-making,²⁵ the ICU environment,²⁶ collaboration between nursing staff and providers,²⁷ and medical counselling for the attending family.²⁸ Families often do not receive information about the status of patients’ health even 48 hours after admission to the ICU.²⁹ Moreover, as physicians are busy, they miss opportunities to listen, acknowledge and address the emotions of families.³⁰

The growing evidence of literature suggests that the family needs in ICU vary in different parts of the world as it is affected by parameters relating to both patient and family members, as well as to ICU staff and infrastructure. This paper wants to understand the family needs in our ICU setup at Bahrain Defence Force Military Hospital. In order to improve the quality of ICU care, we must first measure our performance. Keeping this in mind, our study aimed to assess the levels of satisfaction of family members of patients admitted to the ICU and to identify the areas which need further improvement to upgrade the quality of ICU healthcare.

Methods

Results

A total of 100 relatives of 77 ICU patients responded to the survey. Patient ages ranged from 19 to 92 years (mean age was 63.05 ± 8.27). Responses are summarized in Tables 1 and 2 as N (%) for each factor. Table 3 shows the association of baseline demographics with levels of family satisfaction in the ICU; 93.9% of respondents were immediately related to the patient and the remainder had an extended relationship. The study showed an 18.7% mortality rate. Neither Acute Physiology and Chronic Health Evaluation (Apache) scores (varying from 0 to 71, with a mean of 27.76 ± 18.624) nor the length of patient stays in the ICU (average 10 days) showed significant correlations with the level of family satisfaction. The overall level of family satisfaction was 5.04 ± 1.104 on a scale of 1–6, as illustrated in Figure 1. Table 4 shows the factors that have a statistically significant relationship with satisfaction levels.

Figure 1. The overall level of family satisfaction.

Among all the factors examined as shown in Table 4, two factors, namely receiving complete information from the patient’s relatives and the ease of getting information, demonstrated statistically significant relationships with the dependent variable. Since the coefficients of the significant factors are positive, we deduce that as the completeness of information about the patient and the ease with which it is obtained increases, so does the level of family satisfaction. With a coefficient of determination of 0.980, the model explained 98% of the variability of the independent variable (level of family satisfaction).

The most common comments and suggestions from patients’ relatives were focused on the wish for lengthier visiting hours, for more visitors to be allowed to enter the ICU, and for a daily medical report about the patients, as shown in Figure 2. In addition, relatives wanted to be involved in making decisions and to be able to consult with doctors relatively frequently. Furthermore, 99% of respondents indicated a preference for being present during the morning medical visit.

Figure 2. Frequent comments and suggestions from respondents.

Discussion

Family satisfaction is a key performance measure for assessing the quality of healthcare delivery²⁵ and implementing quality developments.³⁵ Family satisfaction is mainly based on the need for care, support, comfort assurance, courtesy, respect, and compassion, all of which are included in the FS-ICU 24 questionnaire. Moreover, FS-ICU 24 has been used in several previous studies and proved to be a reliable and validated tool for the assessment of family experience in the ICU.^36,37

In this study, the questionnaire was given to 100 family members, all of whom submitted their written replies; this demonstrates that the need for assurance was met. Family members need to be able to trust caregivers and believe that their loved ones are receiving a good level of care, even if they are not present.³⁸ In the context of our study, this means that the families of the patients should have been able to feel confident that giving adverse replies to the questionnaire would not influence the treatment and care given to their respective patients.

In this study, even though overall levels of satisfaction appeared with high percentages, relevant shortcomings still existed, leaving areas for improvement. We attempted to identify such areas of interest and opportunities for improvement. Satisfaction is a complex emotion, influenced by the gap between expectation and perception.²⁵ Satisfaction with the ICU is composed of different parameters; however, two of these are commonly discussed, namely care and decision-making.⁵ In this study, families reported overall satisfaction with parameters relating to the ICU itself and to the patient’s care. The overall FS-ICU scores were relatively high for parameters such as compassion and respect are given to the patient, pain assessment, breathlessness assessment, attention to needs, emotional support, teamwork, care for family, nurse communication, and physician competence which go along with previous reports.¹² However, the scores were lower than those obtained in studies conducted in different parts of the world such as the Canada,³⁹ United Kingdom,⁴⁰ and Germany.⁴¹ Moreover, in this study, the families were least satisfied with the waiting room atmosphere, physicians’ communication, and the frequency of communication. This demonstrates that still there are opportunities to further increase family satisfaction by improving the quality of these parameters.

It is clear from the results that family members wanted physicians to be available for regular discussions in order to obtain information about their relative’s medical condition and prognosis. However, this could be difficult for physicians because they are occupied with taking care of critically ill patients. Generally, nurses play a significant role in coordinating the flow of information between physicians and family members. It has been proposed that effective communication by physicians, skilful discussion of prognosis, and effective shared decision-making are the key elements for quality of care in the ICU.⁴² Importantly, effective communication by ICU staff can improve families’ understanding of the situation and reduce their psychological burden.⁴³

Conclusions

Although overall family satisfaction was high, some areas emerged for improvements, such as the length of visiting hours, frequency of patient status updates, communication with physicians, involvement in decision-making, and presence during medical visits. With this in mind, we propose that periodic assessment of family satisfaction with ICU experience should be carried out as it offers a valuable opportunity to improve the quality of care provided in the ICU.