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Impact on Family Satisfaction^*

The Critical Care Family Assistance Program

^* From the Wellington Consulting Group, Ltd, Gold Canyon, AZ.

Correspondence to: Jane Dowling, PhD, the Wellington Consulting Group, Ltd, 8406 E. Canyon Estates Circle, Gold Canyon, AZ 85218; e-mail: janedowling{at}msn.com

Key Words: communication • critical care • effect size • evaluation • family satisfaction

	Introduction

TOP Introduction Materials and Methods Results Discussion Conclusions References

 
The ICU of a hospital provides sophisticated medical and nursing care to patients facing life-threatening illness or injury. It is estimated that 80% of all Americans will experience an intensive care event, either as a patient or as part of the family of or a friend of a patient during their lifetime. ICUs have been looking to expand their focus beyond patient care and hospital procedures to the consideration of the role of the families of patients in the ICU.

In its simplest terms, this trend is driven by the following two factors: growing evidence that family support positively impacts the recovery rates of ICU patients and high levels of dissatisfaction reported by the families of patients in ICUs. In an effort to improve family member satisfaction and provide better support for the families of ICU patients, The CHEST Foundation, which is the philanthropic arm of the American College of Chest Physicians, in partnership with the Eli Lilly and Company Foundation, is involved in a multiyear study of the Critical Care Family Assistance Program (CCFAP).

Studies on family satisfaction with care and with communication within the critical care setting are limited. Since the descriptive study of family needs in 1979 by Molter,¹ there have been many studies focused on the needs of families and how those needs are met.²³⁴⁵ However, as stated by Heyland et al,⁶ "meeting needs does not guarantee satisfaction." Keeping this caveat in mind, the evaluation study designed for the CCFAP provided measures of family need, as well as of family satisfaction with communication with and care for their loved one by the ICU team and of family satisfaction with their own treatment and care by the ICU team.

The CCFAP study, now in its third year of funding, supports the delivery of a family assistance program model that has the potential to significantly alter the critical care environment for ICU patients and their families. The CCFAP study is a multiyear outcome evaluation study with the dual purpose of determining the efficacy of the CCFAP model as a replicable model in a variety of hospital ICU environments and assessing the impact of the model on family satisfaction with the care and treatment of their loved ones in critical care units. The results of the 3-year family satisfaction study at the CCFAP pilot sites are presented in this article.

	Materials and Methods

TOP Introduction Materials and Methods Results Discussion Conclusions References

 
Questionnaire
A modified version of the family satisfaction survey of Heyland et al⁶ has been validated by the evaluation team as a reliable instrument for evaluating the needs and level of satisfaction of family members who have loved ones in the ICU. Items in the questionnaire were aimed at providing insight into the following areas:

1. Has the introduction of the CCFAP improved family ratings of the quality of communication with various ICU team members (ie, nursing staff, physicians, social worker, chaplain, respiratory therapist, and dietician) [Table 1 ]?
   
2. Has the introduction of the CCFAP improved the family perception of the quality of care received by the patient from various ICU team members (ie, nursing staff, physicians, social worker, chaplain, respiratory therapist, and dietician) [Table 2 ]?
   
3. Has the introduction of the CCFAP improved family satisfaction with a variety of areas surrounding the treatment of both the patient and the family members (Table 3 )?
   
4. Has the introduction of the CCFAP reduced the stress level felt by family members with a loved one in the ICU?
   

Survey responses on the computer are reviewed before analysis, and those that are determined to be incomplete (ie, < 50% of the questions answered) and those with inappropriate answers are deleted from the database. The data collected via the computer survey are downloaded on a quarterly basis and sent to the CCFAP evaluation team for inclusion into a master database. The paper surveys are sent directly to the CCFAP evaluation team for entry into a master database.

Family members completing the surveys included sons, parents, wives, husbands, daughters, grandchildren, brothers, and sisters. The answers for all surveys were reviewed, and it was determined that the individuals completing the surveys were knowledgeable about the communication and care received by the family member.

Statistical Analysis
To compare the difference in mean scores between before and after the introduction of the CCFAP, paired sample t tests or analysis of variance (ANOVA) were employed to determine the statistical significance of the differences. Depending on the number of t tests or analyses, decision rules (ie, the level) had to be adjusted to avoid a type I error. Another main analysis that was used with the data was the utilization of the standardized mean difference to estimate the effect of the CCFAP on certain family satisfaction factors. Effect sizes represent the standardized values of the differences in variables between participation before and after CCFAP implementation. Variables with larger effect sizes indicate stronger program impact. All statistical tests were done using a statistical software package (SPSS, version 11.5; SPSS; Chicago, IL).

	Results

TOP Introduction Materials and Methods Results Discussion Conclusions References

 
Family Perception of Communication With ICU Team Members
Families were asked to rate their perception of the quality of communication between themselves and various ICU team areas during the hospital stay of their loved one. The rating scale was 1 to 5, with 1 being very poor and 5 being very good. Family perception of communication before the implementation of the CCFAP was compared with family perception 2 years after the implementation of the program. Aggregate satisfaction ratings increased for all of the ICU team areas.

Family ratings of communication were > 4.0 at all sites prior to the implementation of the CCFAP. All areas showed improvement in communication, and the results of the ANOVA indicate that social worker communication improved significantly, F_1,382 = 7.38, p < 0.008.

Effect sizes were computed to assess the impact that the CCFAP has had on family satisfaction with communication across the six ICU team components. All effect sizes are positive, with the largest effect size for social work and nursing indicating the likelihood that the CCFAP has had a greater impact on family satisfaction with communication in these two areas.

Family Perception of Quality of Care Provided by ICU Team Members
Families were asked to rate their perception of the quality of care provided to their loved ones by the various ICU team areas. The rating scale was 1 to 5, with 1 being very poor and 5 being very good. The mean ratings increased for all of the ICU team areas, with the largest effect sizes in the areas of social work and respiratory care. With the exception of the dietary area, the before program mean ratings for all other areas were > 4.0, indicating that the majority of families believed that the quality of care was initially high at the pilot sites. There were no significant differences between ratings before and after CCFAP implementation.

Satisfaction of Family Members With Care and Treatment
Families were asked to respond to several questions that addressed the care and treatment of family members in various areas associated with the hospital stay. The mean ratings presented in Table 3 indicate that family perception of the quality of care and treatment of family and family member was generally "good" prior to the implementation of the CCFAP. Although all care areas received ratings of > 4.0 before the initiation of the program, there were mean increases in all ratings after CCFAP implementation. Significant differences were found in family ratings of their involvement in the decision-making process (F_1,532 = 7.35; p < 0.0071.) Effect sizes indicated that the greatest increases in the magnitude of ratings after the implementation of the CCFAP were in the areas of family members being treated with sensitivity and responsiveness, the increase in the flexibility of visiting hours, and in feeling more safe and secure in the hospital environment.

Reduction of Family Stress Level
Family members were asked to report their level of stress/anxiety when their loved ones were admitted to the ICU and to indicate whether the hospital or ICU provided any services or information through the CCFAP to help reduce their stress and anxiety. Families rated their stress level on a scale from 1 to 7 (with 1 being very low and 7 being very high) before and after the provision of CCFAP information or services. The mean rating of family stress level was as follows: before the CCFAP introduction, 5.51; after inclusion of the CCFAP, 3.57; effect size, –0.93. The results of the ANOVA indicated that stress levels were significantly reduced for family members when they received CCFAP information or services (F_1,276 = 76.64; p < 0.0125).

When asked what types of CCFAP services or information were provided to help reduce their stress or anxiety, 52% of the families provided comments that were related to communication (eg, being kept informed, explaining procedures, and answering questions); 25% of the comments represented having a feeling of support from the ICU team; 16% provided examples of hospitality provided, including having a place to stay and food vouchers; and 7% of the comments mentioned the massage therapy that they received as being responsible for reducing their stress.

	Discussion

TOP Introduction Materials and Methods Results Discussion Conclusions References

 
On examination of the mean scores for all of the ICU team member areas, it was apparent that both pilot sites were providing high-quality care (aggregate mean score, 4.20) and that communication was above average (aggregate mean score, 4.22) prior to the initiation of the CCFAP. In this longitudinal study of the two pilot sites for the CCFAP, satisfaction with communication and care continued to increase for families participating in the program. Examination of the effect sizes provides some insight into those areas in which the CCFAP appears to be having a greater impact. In communication, the largest effect sizes are seen both in the areas of social work and nursing. In fact, there was a statistically significant increase in family satisfaction with communication in the social work area. Larger effect sizes are also found in the areas of social work care and respiratory care. These findings allow the sites to further investigate the reasons for the increases in these areas and the smaller increases in other areas. For example, reflection by the project teams on the findings revealed that the increase in the ratings of the respiratory care area might be attributed to the new flexibility of visiting hours and an increased interaction between families and the respiratory therapists during treatments. A major goal of the CCFAP is to strengthen the relationships between the ICU care team and families, ultimately improving family satisfaction. With the positive effect sizes for all team areas, it appears that the program is achieving its goal.

At both pilot sites, families were generally pleased with the treatment and care they had received as a family member from the ICU team prior to the implementation of the CCFAP. Again, there was an increase in satisfaction ratings across all areas, as indicated by the positive effect sizes after the implementation of the program The most profound impact was on the degree to which families felt they were involved in the decision-making process. The positive effect sizes suggest that the program is having an impact on the way ICU teams are treating family members and responding to their needs. Given that the primary concerns of family members include information, flexible visiting policies, and the assurance that their loved one is receiving the best care,⁶ the CCFAP appears to be addressing these concerns in an effective manner. Another area in which the program appears to be having an impact is one area that is targeted by the Joint Commission on Accreditation of Healthcare Organizations, being safe and secure in the hospital environment. The positive effect sizes and individual family comments indicate that that the implementation of the CCFAP has had an impact on the family member feeling safe and secure in the hospital environment.

Families also indicated a statistically significant decrease in stress levels, citing improved communication by ICU team members, availability of hospitality services, and a feeling of support and caring from staff as the primary reasons for the reduction in stress levels.

The results of this current longitudinal study support the findings of other studies of family satisfaction cited in the chapter entitled, "Origins and Development: The Critical Care Family Assistance Program" in this supplement. In several of the cited studies, those factors that are most strongly associated with satisfaction are related to communication and family participation in decision making. The significant findings in the CCFAP longitudinal study are strongest in the areas of communication and decision making. The program is also having a significant impact on reducing family member stress level. Again, qualitative data provide us with insight as to the number one factor in reducing the stress level, communication.

The communication model that has emerged from the CCFAP is described in the chapter entitled, "Emergent Models of Implementation and Communication: The Critical Care Family Assistance Program" in this supplement. It is apparent from the results of the family satisfaction longitudinal study that when the components of this model are implemented, there is a positive impact on family satisfaction with communication. Further research is required to better evaluate the impact of the individual components of the model and whether they lead to an increase in family satisfaction.

	Conclusions

TOP Introduction Materials and Methods Results Discussion Conclusions References

 
Over 20 years of research implied that families were not entirely satisfied with their treatment within an ICU while a family member was under care. Communication, contact with the family member, involvement with decision making, and ICU responsiveness to family requests have been cited as areas of concern. The CCFAP is the first program to seek to address these issues systematically. At two hospitals, a survey of family satisfaction was conducted both before and after the implementation of the CCFAP. The following conclusions can be drawn:

1. The CCFAP program has improved communication between caregivers and family members. While the pre-CCFAP communication pattern at both of these hospitals was at a more-than-satisfactory level, the changes initiated within the CCFAP improved communication at all levels. The most significant improvements were noted with nursing and social work. Since these two areas have the most consistent contact with both patients and family, their interaction has had the most persistent impact on the improvement of communication. Since the CCFAP program calls on all staff to operate as a team, it is possible that improved communication patterns would be attributed to the most visible representatives of the team (ie, nursing and social work). The improved scores are indicative that the staff of the ICU has become more attuned to families’ needs and has established improved priorities in communicating with families.
   
2. While families have consistently rated the quality of care administered by the ICU at a high level, improvement in this perception was immediately noticed after the implementation of the CCFAP. Physicians, nursing, and respiratory care received the highest ratings, with the greatest effect size being noticed in nursing and respiratory care. This widespread improvement across all areas strongly suggests that it is the active involvement of this multispecialty team of physicians, nurses, therapists, and all who serve patients in the ICU in understanding and implementing the CCFAP that has contributed to this positive increase.
   
3. Prior research had suggested a number of areas that were likely to prove critical in determining family satisfaction with the care in the ICU. These factors included decision making, safety and security, comprehension of medical procedures, and an understanding of the treatment the patient was receiving. The strong focus that the CCFAP brought to these areas resulted, again, in improved family satisfaction. The specific steps taken by the CCFAP to improve performance in all of these areas have emerged from the ongoing dialogue that is conducted by the team, making day-to-day evaluation a key feature of the CCFAP and resulting in the ability of the ICU team to respond to family needs within a structured feedback model.
   
4. Much of the research had emphasized that a significant problem for families with loved ones in the ICU was the anxiety level that appeared to increase the longer the confinement lasted. That anxiety appeared to stem both from the uncertain survival status of the loved one, as well as from the difficulties experienced in obtaining information. Each ICU participating in the CCFAP has observed that stress in families appears to decrease in inverse ratio to the percentage that communication increases. The efforts made in communication resulted in a significant decrease in anxiety. Over the years, anxiety and concern on the part of the family had proven to be major barriers affecting communication between staff and family. The CCFAP, in creating a proper atmosphere for communication, and in providing a livable space with basic amenities within a friendly and open atmosphere, fostered an open stress-reducing dialogue.
   
5. Opportunities for additional research in the CCFAP continue to be present. The findings that the CCFAP had a positive influence on areas that had been persistent problems suggest that further longitudinal studies be undertaken to examine its impact more fully. Topics for further study would include the following:
   

With the focus of the CCFAP on improved communication, what specific aspects of the program had the greatest impact on improved communication and increased family satisfaction?

What impact has the CCFAP model had on length of stay in the ICU? Can more rapid recovery be traced to any aspects of the CCFAP?

Has the collaboration of a multispecialty staff resulted in treatment that is more cost-effective?

What aspects of the hospitality program can be demonstrated to contribute most to family satisfaction?

Has the emphasis on patient and family satisfaction within the ICU had an impact on hospital administration and key management decisions?

	Footnotes

 
Abbreviation: CCFAP = Critical Care Family Assistance Program

	References

TOP Introduction Materials and Methods Results Discussion Conclusions References

 

1. Molter, N (1979) Needs of relatives of critically ill patients: a descriptive study. Heart Lung 8,332-339[ISI][Medline]
2. Johnson, D, Wilson, M, Cavanaugh, B, et al Measuring the ability to meet family needs in an intensive care unit. Crit Care Med 1998;26,266-271[CrossRef][ISI][Medline]
3. Azoulay, E, Pochard, F, Chevret, S, et al Meeting the needs of intensive care unit patient families. Am J Respir Crit Care Med 2001;163,135-139[Abstract/Free Full Text]
4. Foss, KR, Tenholder, MF Expectation and needs of persons with family members in an ICU as opposed to a general ward. South Med J 1993;86,380-384[CrossRef][Medline]
5. Price, DM, Forrester, DA, Murphy, PA, et al Critical care family needs in an urban teaching medical center. Heart Lung 1991;20,183-188[Medline]
6. Heyland, DK, Rocker, GM, Dodek, PM, et al Family satisfaction with care in the intensive care unit: results of a multiple center study. Crit Care Med 2002;30,1413-1418[CrossRef][ISI][Medline]

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