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Weekly UpdatesABSTRACT
Recent initiatives encourage a family presence during cardiopulmonary resuscitation and invasive procedures and more open visitation policies in intensive care units (ICUs). This study investigated perceptions of needs of those visiting and working in six ICUs. The needs of family members visiting patients with critical illness and nurses working in ICUs were measured using the Critical Care Family Needs Inventory. Data were collected prospectively using a convenience sample of 101 patients, family members, and nurses. Hierarchical cluster analysis identified the themes of (a) emotional resources and support, (b) trust and facilitation of needs, (c) treatment information, and (d) feelings. Family members and nurses differed significantly on three of the four themes (p = .000).
This is important information for neuroscience nurses and other healthcare professionals to consider in providing care, setting visiting policies in ICUs, and developing approaches such as family-centered care.
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It is a very stressful time for a family when one of its members is hospitalized in an intensive care unit (ICU); some even define this as a time of crisis for families. The response by healthcare professionals is varied in types of visitation policies and the level of family involvement advocated.
The Institute of Medicine (2001) strongly recommended that healthcare delivery systems become more patient centered, which in ICUs translates into increased family involvement Many organizations, including the American Association of Critical-Care Nurses and the Emergency Nurses Association, issued statements that family members of patients undergoing cardiopulmonary resuscitation should be given the option of being present during cardiopulmonary resuscitation and other invasive procedures (American Association of Critical-Care Nurses, 2004; Emergency Nurses Association, 2001). The Institute for Healthcare Improvement advocated the liberalizing of visiting hours in ICUs (Berwick & Kotagal, 2004). The American College of Critical Care Medicine Task Force issued clinical practice guidelines for support of the family in the patient-centered ICU. Two pertinent recommendations were the following: (a) Open visitation in the adult ICU should be structured to allow flexibility for patients and families and be determined on a case-by-case basis, and (b) the patient, family, and nurse should determine the visitation schedule, collectively taking into account the best interest of the patient (Davidson et al., 2007). It is clearly important for neuroscience nurses and all healthcare professionals to have an understanding of the needs of family members to provide support in the most appropriate manner in ICUs.
The purposes of this article were to provide a review of the literature and report the findings of a study that identified family members' and nurses' perceptions of needs of individuals visiting and nurses caring for patients in six ICUs. This was considered an important first step before redesigning visiting policies at our institution in light of recommendations for patient-centered ICUs.
Review of Literature
The basic needs of families have been summarized as (a) information, (b) reassurance, (c) support, and (d) ability to be near the patient (Damboise & Cardin, 2003).
Two important concepts that emerged from the literature and will be explored further are family members' perceptions of needs and nurses' perceptions of the needs of family members visiting patients in ICUs.
Identifying Family Needs
The Critical Care Family Needs Inventory (CCFNI) was designed in 1976 (Molter, 1976), and it has been refined and used in multiple studies in the last four decades. An early study used the CCFNI to identify the top five needs of family members (n = 40) of patients in (mostly cardiac) critical care units. The individual needs ranked most important were identified as (a) having hope, (b) feeling that the hospital personnel cares for the patient, (c) having a waiting room near the patient, (d) being called at home with changes, and (e) knowing the prognosis (Molter, 1979). Most of the family needs, and all of those identified as the 10 most important (out of 45 rated), were met more than 50% of the time. Another study used the CCFNI in cardiac units to assess the level of need satisfaction perceived by 52 family members (Lynn-McHale & Bellinger, 1988). Family members reported being relatively satisfied with having their needs met when personal support systems, visitation, and information were considered.
Hickey (1990) reviewed the literature published over the course of 13 years related to the needs of families of patients with critical illness. Eight studies were identified that asked the research question, "What are the needs of families of patients with critical illness?" Only three of the studies adequately described the sample characteristics, but small sample sizes diminished the external validity in all of the studies. Hickey identified that the settings and practices with families, such as visiting policies, philosophies toward families, and hospital resources available to families, were inadequately described in the eight studies reviewed. Given the identified limitations of small and inadequately described samples, a need clearly exists to continue to study the important question of the needs of family members in studies with more rigorous designs.
Using the CCFNI (Mathis, 1984), researchers have studied the needs of family members visiting neurosurgical patients. One study reported that family members of patients with critical illness without acute brain injury (n = 15) perceived the degree of importance of personal needs differently compared with family members of patients with critical illness with an acute brain injury (n = 11). Another study using the CCFNI (Engli & Kirsivali-Farmer, 1993) supported the finding of Mathis (1984) and reported statistically significant differences in the perceived personal needs of family members of patients with critical illness with acute brain injury (n = 15) compared with those of family members of patients with critical illness without acute brain injury (n = 27). A qualitative study of the experiences of family members of patients emergently admitted to a neurological ICU reported that family members had two main goals: The first was to assure their loved one was receiving the best care possible, and the second was to maintain a connection with the person (Lam & Beaulieu, 2004). Although these are important exploratory studies, all included small samples and represent mainly one type of neurological patient, those with acute brain injury.
The needs of family members from cultures other than Western cultures have also been explored. The needs of Chinese family members have been identified in a primarily noncardiac (neurosurgical) population by several groups (Leung, Chien, & Mackenzie, 2000; Tin, French, & Leung, 1999) using a translated version of the CCFNI. Fifty-two family members rated the first five needs as (a) being called at home about changes in the patient's condition, (b) knowing the expected outcome, (c) being assured that the best care possible is given to the patient, (d) knowing the specific facts concerning patient's progress, and (e) having questions answered honestly (Tin et al., 1999). A multicenter study in France (Azoulay et al., 2001) used the CCFNI with 920 family members and identified seven predictors of family satisfaction.
A researcher in Sweden investigated the experiences of partners of persons with critical illness in the ICU setting and the perspective of the critical care nurses (Engstrom, 2006). This qualitative study looked at the experience of partners and identified three themes of being present, putting oneself in second place, and feeling that nothing else mattered (Engstrom & Soderberg, 2004). Collectively, these studies done in Hung Kong, France, and Sweden illustrate the importance of cultural aspects of perceptions as the population in the United States becomes more multicultural.
Nursing Perceptions of Family Needs
In addition to investigating family needs, Molter's (1979) research also asked if the family needs were being met and, if so, by whom. Most of the needs of family members were identified as being met by nurses most of the time.
Another study used two forms of the CCFNI, one for family members and another for critical care nurses on which the nurses indicated the level of satisfaction that they believed the family members of a patient with critical illness had relative to each need statement. The 92 critical care nurses were moderately accurate at identifying the extent to which family members perceived their needs as being met, but there were numerous areas of disagreement (Lynn-McHale & Bellinger, 1988).
A qualitative study (Engstrom, 2006) used focus group discussions with 24 critical care nurses to describe the nurses' experiences of close relatives in the ICU. It was reported that close relatives were regarded as a prerequisite for critical care nurses to give good nursing care to meet the needs of the patient with critical illness.
Two studies (Leung et al., 2000; Tin et al., 1999) reported that neurosurgical nurses identified that the perception of the needs of family members does not always match the needs identified by the family members. Of the 10 most important family needs, 4 statements showed significant differences in perceived importance by the family members and by the critical care nurses. For example, family members rated "to have questions answered honestly" as first in their ranking, whereas the critical care nurses ranked it as sixth (Leung et al., 2000).
Another qualitative study (Lam & Beaulieu, 2004) explored the experiences of family members of patients with an emergent admission to a neurological ICU. They reported that families are motivated by the two goals of (a) assuring their loved one is receiving the best care possible and (b) wanting to maintain a connection with the person. These studies illustrate the importance of continuing to investigate whether the type of ICU influences the nurse's perceptions of the needs of the family members.
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