Measuring Family Satisfaction With Care Delivered in the Intensive Care Unit

It is a common practice in health care systems for administrators to use data gleaned from Press Ganey surveys or Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys to direct practice changes aimed at improving outcomes and patients’ experience.¹⁴  Because these widely used surveys do not directly measure patient and family satisfaction with care received in the ICU, it is difficult to understand the needs and perceptions of critically ill patients and their families. This shortcoming may hinder initiatives to improve quality and processes of care in ICUs.

Because patients’ families have an important role in sharing information and engaging in health care decisions, it is critical to understand how families perceive care in the ICU. Moreover, family satisfaction in the ICU has been identified as a quality indicator of ICU care¹³  and a surrogate marker of customer care.⁷  Tools selected for measuring family satisfaction should include measurement of family satisfaction with decision-making. The Family Satisfaction in the ICU 24-item (FS-ICU-24) questionnaire is a reliable and valid tool used to measure family satisfaction with care and decision-making in the ICU.^15,16  Data from this questionnaire are useful for informing improvements in quality and processes of care in the ICU.

In this competitive health care environment, family satisfaction in the ICU is an important measurement to consider when evaluating quality and processes of care. Family satisfaction had not been measured at the study site. Therefore, measurement of family satisfaction was a first step in a series of steps aimed at improving processes of care in the study site’s ICU.

The specific aim of this study was to measure family satisfaction with care and decision-making in a medical and surgical ICU. A secondary aim was to assess the feasibility of using the FS-ICU-24 as an ongoing measure of family satisfaction. Last, data on family satisfaction were analyzed and recommendations for unit-based quality and process improvement initiatives were made.

This study was approved by the institutional review boards at Sacred Heart University and the study hospital. Consent was implied if the family member completed and returned the FS-ICU-24 questionnaire.

The setting was a 12-bed medical-surgical ICU in a small community hospital in Massachusetts that is dedicated to caring for critically ill patients. Patients’ diagnoses included septic shock, pneumonia, multisystem organ failure, gastrointestinal hemorrhage, and complications associated with polysubstance abuse. The sample also included patients who underwent emergent or elective surgery. Typical critical care interventions included mechanical and noninvasive ventilation, invasive and noninvasive testing, and hemodynamic monitoring. The nurse to patient ratio was generally 1 to 2 and was 1 to 1 for gravely ill patients. The mean daily census was 7 patients. The mean length of stay was 3.5 days. The mean age of the patients was 76.6 years.

In this ICU, 4 medical attending intensivists rotate every 2 weeks to supervise the care of medical patients. The surgical team, with the medical team acting as a consulting service, primarily cares for the surgical patients. The medical and surgical team structure includes a first-year intern, a second-year resident, a third-year chief resident, and an attending physician. The medical director of the ICU and senior nursing leaders endorsed this study.

The inclusion criteria (see Figure) were based on previous research.^17,18  Family members who met the inclusion criteria were given study packets. The criterion requiring the family member to have visited the patient at the bedside at least 2 times for more than 10 minutes was confirmed by direct observation by the unit secretary, nurse educator, or principal investigator. Family members of patients being transitioned from critical care to end-of-life care were excluded because in previous studies such family members tended to report high satisfaction with care.

The FS-ICU-24 measures satisfaction with care (14 items) and satisfaction with decision-making (10 items).¹⁵  In addition, 3 free-text questions ask how to make the ICU care provided better, what things the staff did well, and for any comments or suggestions that may be helpful. The FS-ICU-24 is completed by using a 5-point Likert scale: 1 = excellent, 2 = very good, 3 = good, 4 = fair, 5 = poor; a score of 6 indicates a response of not applicable. This survey has well-established reliability with a Cronbach α of 0.92 for satisfaction with care and 0.88 for satisfaction with decision-making. For this study, the Cronbach α for the total FS-ICU-24 was 0.95, for the satisfaction with care subscale was 0.93, and for the satisfaction with decision subscale was 0.87, indicating excellent reliability. High scores mean satisfaction with care and decision-making. Scores were calculated for the total FS-ICU-24 and for the 2 subscales (satisfaction with care and satisfaction with decision-making). The questionnaire takes about 15 minutes to complete. The questionnaire and scoring instructions are available online for free at http://thecarenet.ca/.

From October 1, 2014, through December 31, 2014, on all shifts, family members who met the inclusion criteria were given a packet that included an explanation of the study, the FS-ICU-24 questionnaire, and basic demographic questions. Family members were asked to complete the survey and return it in one of the locked boxes located in the ICU or the family waiting area.

An information session about the study was held for the ICU staff. A unit secretary, the nurse educator, and the principal investigator recruited patients’ family members for participation in the study. In the family waiting area, a poster described the study and instructed interested family members to contact the unit secretary or nurse educator. Packets that were not returned or returned blank were recorded as refusals.

Data analysis was conducted by using SPSS for Windows 18 (SPSS Inc). For ease of understanding the FS-ICU-24 values, individual items were transformed from a Likert 5-point scale to a scale from 0% to 100%, with higher values indicating greater satisfaction (25% = fair, 50% = good, 75% = very good, and 100% = excellent). No one died in the ICU during the study period, so questions 11 through 13 were not included in the analyses. For the satisfaction with care subscale, individual means were calculated by using the total number of questions answered as the denominator for any family member who answered not applicable. These individual means were used in calculating the total mean score on the FS-ICU-24. This imputation was not necessary for the family satisfaction with decision-making subscale because only 1 family member who answered not applicable in this subscale had missing data in the satisfaction with care subscale, so their total FS-ICU-24 could not be calculated.

Two researchers reviewed the free-text questions, 14 through 16, on the family satisfaction subscale and identified common descriptors reported by family members for each question. Another researcher, looking for any difference in descriptors, carried out a separate review of the free-text answers, and no discrepancies were found.

Sixty-two family members of patients were given questionnaires, and 40 family members returned the questionnaire. Table 1 describes the demographics and baseline characteristics of the 39 family members who returned complete questionnaires. The majority of the family members were female, white, and college educated. The mean age of the family members was 50.15 (SD, 15.92) years. The majority of family members were a child or spouse of the patient. Extended family members included siblings, grandchildren, nieces, nephews, and daughters-in-law. Most of the patients had diagnoses of medical diseases (pneumonia, gastrointestinal bleeding), drug overdose, or severe sepsis. The remainder of the patients had undergone either elective or emergent surgery. The mean length of stay in the ICU was 3.5 days. The study ICU used QuadraMed software (QuadraMed Affinity Corp) to calculate nurse staffing on the basis of patient acuity with nurse to patient ratios of 1 to 2 and 1 to 1 during the study.

The mean overall FS-ICU-24 score was 72.24% (SD, 14.87%; missing, n = 9). The mean score on the satisfaction with care subscale was 70.87% (SD, 16.51%; missing, n = 6). The median score was 71.15% (interquartile range, 13%), indicating that most family members reported good to very good satisfaction with care. The mean satisfaction with decision-making was 72.03% (SD, 16.61%). The median score was 68.75% (interquartile range, 10.25%), indicating that most family members reported good to very good satisfaction with decision-making.

Table 2 displays the free-text answers to FS-ICU-24 questions 14 through 16 organized by the categories of communication, staff, care/comfort, and physical environment and the positive and negative descriptors within these 4 categories. Family members wrote mostly positive comments about staff and the care and comfort that the staff provided. Fifty percent (n = 12) of family members’ free-text responses included the need for better communication with health care staff. Moreover, of the 24 families who completed the free-text responses, none had positive comments about the physical environment, instead offering suggestions to improve the waiting room and parking.

The FS-ICU-24 was feasible for measuring family satisfaction in the study ICU. This questionnaire provided rich data, with nearly every family member answering the free-text questions, addressing aspects that the ICU was doing well and things that needed improvement.

Results for satisfaction with care and decision-making from this study were slightly lower than results reported for other studies done in the United States^12,18  and other countries^13,19  that used the FS-ICU-24. The mean satisfaction with care and decision-making was in the “good” range, whereas other studies^12,13,18,19  reported means in the “very good” range (> 77% for satisfaction with care; > 75% for decision-making). In a recent study²⁰  conducted in Greece, researchers found that satisfaction with care was much higher (mean [SD], 91.8% [13.0%]) and satisfaction with decision-making was much lower (65.2% [8.5%]) than our results. Variation in results may be explained by differences in patients’ severity of illness, the family member completing the survey, cultural expectations, and country-specific differences in ICU practices and health care systems. In the present study, families of patients who were transferred to palliative care or died were not asked to complete the FS-ICU-24. Moreover, family members had to visit the patient at least twice, at the bedside, for at least 10 minutes each time, and visiting hours were unrestricted while the patient was in the ICU.

In the free-text answers, 50% of the responding family members reported the need for better communication with health care providers and the need for timely, accurate information. Researchers in other studies measuring family satisfaction in the ICU also reported a need for better communication between health care providers and patients’ families^11,21,22  and up-to-date information about changes in a patient’s condition.²¹  A recent review²³  emphasized that providing patients’ families with proactive communication strategies and information may increase families’ satisfaction in the ICU.²⁴ 

Family members expressed only negative comments about the ICU environment. This result is similar to the findings of Henrich and colleagues,¹¹  where positive comments were less commonly reported in the free-text questions of the FS-ICU-24 than were negative comments regarding the waiting room environment. This result emphasizes that small changes to the care environment such as having smart phone chargers may improve the experience for and increase the satisfaction of patients’ families.

Fewer free-text comments were made regarding the staff and care/comfort, and the responses were overwhelmingly positive. This result was consistent with the findings on overall family satisfaction being a rating of “good.” However, these results suggest that there is room for improvement.

Collecting data related to satisfaction with the care while a patient remains hospitalized can potentially provide false-positive results. Additionally, the self-selected family member responding may not have represented the collective view of all family members. Last, the sample size of 40 was small and we had a nonresponse rate of 35%. The inclusion criteria most likely reduced our sample size.

The health care providers, staff, and researchers involved in this study reviewed the study results and complied their recommendations for process and quality improvements in the ICU (Table 3). The first step toward implementing the recommendations was to identify a change agent from nursing and medicine who could facilitate the selected recommendations collaboratively in the ICU. The next step was to share the results with the ICU staff, get their buy-in, and identify individuals interested in championing the different recommendations. For example, an interprofessional collaboration between social work and pastoral care can offer conflict management workshops for ICU staff. Nursing staff can create and pilot test a template for the care journal. To address the recommendations provided by patients’ family members, nursing staff can implement a facilitated sense-making intervention card for families.²⁶  Moreover, nursing and physician staff can create a combined staffing template for patient-care provider continuity. The PDCA (plan-do-check-act) method can be used for quality and process improvements, and any changes should be assessed to determine whether they would make a positive difference in care and whether the change is sustainable.

This study yielded new knowledge about family members’ experiences and needs in the ICU. In particular, communication and physical environment were identified as areas contributing to family dissatisfaction with their experience in the ICU. Interventions can and will be targeted to meet these specific needs in the ICU.