The Chinese family-centered care survey for adult intensive care unit: A
psychometric study

Wen-Ling Wang RN, PhD, Jui-Ying Feng RN, PhD, Chi-Jen Wang PhD,
Jing-Huei Chen MSN

PII: S0897-1897(15)00087-7
DOI: doi: 10.1016/j.apnr.2015.04.003
Reference: YAPNR 50657

To appear in: Applied Nursing Research

Received date: 21 September 2014

Revised date: 8 April 2015
Accepted date: 12 April 2015

Please cite this article as: Wang, W.-L., Feng, J.-Y., Wang, C.-J. & Chen, J.-H., The
Chinese family-centered care survey for adult intensive care unit: A psychometric study,
Applied Nursing Research (2015), doi: 10.1016/j.apnr.2015.04.003

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Title page

Title：The Chinese family-centered care survey for adult intensive care unit: A
psychometric study

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Running Head: Chinese Family-Centered Care Survey

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Authors: Wen-Ling Wang, RN PhD1; Jui-Ying Feng, RN PhD2; Chi-Jen Wang,

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PhD3 ; Jing-Huei Chen, MSN 3

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1
Former-Associated Professor, Department of Nursing, College of Medicine, National
Cheng Kung University

2
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Associated Professor & Nursing Supervisor, Department of Nursing, College of
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Medicine, National Cheng-Kung University/Hospital
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Assistant Professor, Department of Nursing, College of Medicine, National
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Cheng-Kung University
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Registered Nurse, Department of Nursing, Tri-Service General Hospital Penghu
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Branch
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Address correspondence to: Jing-Huei Chen,

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Tel: 886-7-5547939 Fax: 886-7-6821281

Email： t26961027@gmail.com

The institution at which the work was performed:

The National Cheng Kung University Hospital, Taiwan

Key words (CINAHL Subject Heading List) ：Family Centered Care、critically ill adults、
Instrument Validation、Questionnaires -- Evaluation

Grant or other financial support used in the study: None

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Acknowledgements

The authors send our appreciation and special thanks to all the participants who

had devoted time to complete the survey and to all the research partners to payout all

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their research efforts. We also owe a special debt of gratitude to Dr. Fran Anderson for

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editing this article.

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CONTRIBUTIONS OF AUTHORS

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All four authors participated in manuscript development.
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Contributions
Study design: Wang WL , Chen JH ;
data collection and analysis: Wang WL , Chen JH , Feng JY and Wang CJ
manuscript preparation: Wang WL , Chen JH ;.
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Conflict of interest
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None.
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The Chinese family-centered care survey for adult intensive care units: A

psychometric study

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Abstract

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Aims This study aimed to develop a family-centered care survey for Chinese adult

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intensive care units and to establish the survey’s psychometric properties.

Background Family-centered care (FCC) is widely recognized as an ideal model of

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care. Few studies have explored FCC perceptions among family members of adult
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critical care patients in Asian countries and no Chinese FCC measurement has been

developed.
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Methods An English version of the 3-factor family-centered care survey for adult
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intensive care units (FCCS-AICU) was translated into Chinese using a modified back
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translation procedure. Based on the literature review, two additional concepts,

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information and empowerment, were added to the Chinese FCCS-AICU. The

psychometric properties of the Chinese FCCS-AICU were determined with 249

family members from a medical center in Taiwan and were tested for construct and

convergent validity, and internal consistency.

Results Both the monolingual and bilingual equivalence tests of the English and

Chinese versions of the 3-factor FCCS-AICU were supported. Exploratory factor

analysis supported the 5-factor structure of the Chinese FCCS-AICU with a total
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explained variance of 58.34%. The Chinese FCCS-AICU was correlated with the

Chinese Critical Care Family Needs Inventory. Internal consistency, determined by

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Cronbach’s α, for the overall scale was .94.

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Conclusions The Chinese FCCS-AICU is a valid and reliable tool for measuring

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perceptions of FCC by family members of adult intensive care patients within

Chinese-speaking communities.

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Key words: Family-centered care, Adult, Intensive care, Psychometric evaluation
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Family-centered care (FCC) has been implemented for decades, mainly in pediatric
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long term care facilities in western countries. FCC has been shown to decrease
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hospitalized children’s postoperative pain, encourage early ambulation, shorten

hospital stay, and reduce readmission rates.1,2,3 The definition of FCC varied among

these studies, which made it difficult to compare the effectiveness of FCC models

across sites. After reviewing the effects of FCC models for hospitalized children,

Shields et al. (2007) suggested that more rigorous research is needed to examine the

effectiveness of the FCC model in different settings.4 Developing a multi-faceted

instrument that reflects the concepts of FCC is a crucial step in rigorous research.
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Moreover, most FCC studies had been conducted primarily in western countries, such

as the United Kingdom and North America.3,5 Few studies have investigated the

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effectiveness of FCC in different age or cultural groups, such as Chinese-speaking

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patients in adult intensive care units (AICUs) and their families.

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In the FCC model, a patient and his or her family are perceived as the unit of care.

Respecting unique cultural backgrounds, healthcare providers collaborate with each

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unit of care to help them, cope with the illness, create a care plan, and provide care to
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the patient.5,6,7 Since Shelton et al (1987) and Hutchfield (1999) proposed the FCC,6,8

several measures of the FCC of this model have been published, including Measure
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of Processes of Care, Family Centered Behavior Scales, the Family Centered Care
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Questionnaire and the Family Centered Care Survey (FCCS).9 These instruments have
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mainly been used with families of pediatric patients, which may not be appropriate in
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adult critical care settings. To assess the efficacy of FCC in adult intensive care units,

Mitchell et al. (2009) revised the FCCS to develop the family-centered care survey for

the adult intensive care unit (FCCS-AICU) and establish its psychometric

properties.10 The FCCS-AICU scale includes the concepts of respect, collaboration

and support; it does not include information and empowerment.

Respect, collaboration, support, and information are frequently outlined in the

literature as the core concepts of FCC.6,11,12 Paliadelis et al. (2005) suggested adding
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empowerment as an FCC concept.12 The Taiwan people, predominantly Chinese

speakers, are influenced by their filial responsibility and obligation to care for their

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family members.13 For the Taiwanese, illness is a family issue, and caring for a sick

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member is the responsibility of the whole family. Not only do family members

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participate in caring for the sick one, but also they are actively involved in making

decisions regarding treatment.14 In a Hong Kong family needs study, Chien et al.

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(2006) found that the top needs identified by families of AICU patients were
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information (knowing why specific treatments or care was done, empowerment (being

able to provide bedside care), and support (being able to talk about the patient’s death
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and their own negative feelings.15 In a qualitative study, Hung (2007) explored
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pediatric patients parents’ and nurses’ perceptions of FCC in a Taiwanese medical

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center ‘s pediatric critical care unit.11 Findings indicated that information and
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empowerment were the most valued and of most concern by families and nurses.

Information and empowerment are can provide additional value to the original

3-factor FCCS-AICU.10 The purposes of this study, therefore, were to develop a

5-factor FCCS-AICU in Chinese and establish its psychometric properties. The

Chinese FCCS-AICU can assess the perception of FCC by Chinese-speaking families

of AICU patients and contribute to understanding the clinical applicability of FCC in

the Chinese-speaking communities.

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Methods

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A two-stage process was adopted to develop and validate the 5-factor Chinese

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FCCS-AICU. First, the five-step process of scale translation and validation proposed

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by Wang et al. (2006) was used to translate the 3-factor FCCS-AICU (20 items) into

Chinese.16 Forty-one bilingual and three monolingual subjects were recruited to test

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the translation equivalence. At the 2nd stage, based on the literature review, two
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factors, information and empowerment, were added to the 3-factor Chinese

FCCS-AICU. Fourteen new items were added to create the 5-factor Chinese
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FCCS-AICU, resulting in a total of 34 items. Three experts in the medical field were
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invited to evaluate face validity of the Chinese 5-factor FCCS-AICU. A total of 277
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AICU patient family members at a medical center in Taiwan were recruited to test the
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psychometric properties of the Chinese 5-factor FCCS-AICU.

Stage I: Instrument Translation and Equivalent Tests

Permission for translation was obtained from the developer of the 3-factor

FCCS-AICU. A five-step process of scale translation and validation was followed to

ensure translation equivalence.16 The first three steps consisted of translation, panel

review, and back-translation. Two bilingual Chinese experts (one with a master’s

degree majored in English and the other a doctorally prepared nurse obtained her PhD
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in the United States) translated the 3-factor FCCS-AICU from English to Chinese.

Three family members of AICU patients were invited to read the 3-factor Chinese

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FCCS-AICU draft and provide suggestions for clarity. Considering these suggestions,

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a review panel (four authors plus one master’s-prepared AICU head nurse) then

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evaluated the draft for language clarity and cultural relevance. The resulting 3-factor

Chinese FCCS-AICU was translated into English by two Chinese bilingual experts

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who had no previous exposure to this instrument. Both were Taiwanese (one had
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earned a master’s degree in counseling in England and the other is a PhD prepared

assistant professor in an American university). The first expert translated the 3-factor
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Chinese FCCS-AICU into English, and the second expert edited this translation.
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Translation equivalent tests were performed by monolingual and bilingual subjects.

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The instrument’s reliability was determined by Cronbach’s α. In the monolingual test,

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three English speaking Americans, all with master’s degrees, were invited to compare

the original 3-factor FCCS-AICU with the back-translated English version of the

Chinese 3-factor FCCS-AICU for translation compatibility and similarity on a

seven-point scale.16 A score ≥ 4 points indicated large differences in

comparability/semantics. In this study, the average score for translation similarity was

2.26 (± 0.45) and for comparability, it was 2.45(± 0.45), which indicated the Chinese

3-factor FCCS-AICU was equivalent to the original 3-factor FCCS-AICU English

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version. The monolingual speakers disagreed only on 2 out of 20 items. These 2 items

were elaborated on the review panel.

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The purpose of the bilingual test was to examine if there were any differences when

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the same subjects completed both the English version of the 3-factor FCCS-AICU and

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the Chinese version of the 3-factor FCCS-AICU. Because of the difficulty in finding

bilingual AICU family members, 41 Chinese undergraduate students majoring in

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English at a southern Taiwan university were recruited. They were asked to answer
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the questionnaires based on past similar hospitalization experiences. They were told

that if they did not have such experiences, they should imagine themselves as family
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members of AICU patients while they answered the questionnaires. The students
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filled out the English and Chinese 3-factor FCCS-AICU one week apart. The average
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item correlation between both versions of the 3-factor FCCS-AICU was 0.70 for
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respect, 0.70 for support, and 0.73 for collaboration. The overall Cronbach’s α for the

English 3-factor FCCS-AICU was 0.84 and 0.94 for the Chinese 3-factor

FCCS-AICU. The results of both monolingual and bilingual tests revealed that the

Chinese 3-factor FCCS-AICU was translated adequately for use with the

Chinese-speaking population.

Stage II. Developing and Testing the 5-factor Chinese FCCS-AICU

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Once translation equivalence of the Chinese 3-factor FCCS-AICU (20 items) was

established, the researchers added two factors, information and empowerment, to the

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instrument based on the literature review. A total of 14 items were added to develop

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the Chinese 5-factor FCCS-AICU. All 34 items, listed in Table 1, were closely

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examined and rearranged into 5 factors that best represented their conceptual

definition.

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Expert content validity test of the Chinese 5-factor FCCS-AICU

Three Chinese experts (a masters-prepared AICU head nurse, an AICU physician, and
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a PhD prepared nursing professor) were invited to validate the Chinese 5-factor
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FCCS-AICU content. Each item was rated on a four-point scale based on relevance,
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significance, and clarity. Content Validity Indexes (CVI) were calculated by the
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proportion of items that received a rating of 3 or 4. The CVI values from the first

expert ranged from 0.72 to 1.00. All items were retained; eleven were revised based

on the expert’s opinions. The CVI values from the second expert ranged from 0.95 to

1.00. All experts agreed that the items on the Chinese 5-factor FCCS-AICU reflected

family centered care (FCC).

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Setting and subjects for testing the Chinese 5-factor FCCS-AICU psychometric

properties

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Construct validity, convergent validity, and internal consistency of the Chinese

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5-factor FCCS-AICU were tested with input from 249 family members of patients in

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four AICUs at a 1200-bed tertiary care medical center and teaching hospital in Taiwan.

The study was approved by the hospital research ethics committee. Data were

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collected between June and November 2010. In this study, family member was
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defined as being related to a patient through blood, marriage, cohabitation, or

adoption. The inclusion criteria for subjects were being: (1) a family member of a
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patient who stayed in the AICU more than 3 days; (2) over 18 years of age; able to
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read Chinese characters or communicate in Taiwanese; and (3) signing a consent form.
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The exclusion criterion was being engaged in a medical malpractice dispute. If more
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than one family member met inclusion criteria, the authors invited the significant

other or main caregiver who visited the patient most frequently to participate. All

subjects were informed that their confidentiality would be respected and they were

free to choose not to participate in the study without affecting their relative’s current

or future medical treatment. Subjects completed a demographic sheet, the Chinese

5-factor FCCS-AICU and the Chinese Critical Care Family Needs Inventory

(C-CCFNI), which took approximately 20 minutes. After completion of the

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questionnaires, subjects were given a gift voucher as incentive thank-you for

participating.

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Instruments

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Two instruments were used in this study, the Chinese 3-factor FCCS-AICU and the

C-CCFNI. The Chinese 3-factor FCCS-AICU served as the basis for developing the

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Chinese 5-factor FCCS-AICU. The C-CCFNI was used to test convergent validity of
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the Chinese 5-factor FCCS-AICU.

3-factor FCCS-AICU. The FCCS was developed by Shields and Tanner (2004) and
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documented as an effective tool to measure sick children’s parents’ perceptions of

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FCC in both inpatient and outpatient settings.9 Mitchell et al. (2009) modified the
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FCCS to develop the 3-factor FCCS-AICU to assess the implementation of FCC

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within AICU settings. The 20-item 3-factor FCCS-AICU includes, respect, support,

and collaboration.10 All factors were based on questions about how often a stated

event occurred and respondents were asked to indicate their perceptions on a 4-point

Likert-type scale. Higher scores indicate perceptions of higher levels of FCC in the

AICU. In the study by Mitchell et al. (2009) with 174 Australian subjects, Cronbach’s

α was 0.62 for respect, 0.80 for support, and 0.70 for collaboration.10 In this study

with 249 Chinese-speaking family members of AICU patients, Cronbach's α for the
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Chinese 3-factor FCCS-AICU was 0.69 for respect, 0.82 for support, 0.77 for

collaboration, and 0.88 overall.

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C-CCFNI. The C-CCFNI measures the needs of family members of critically ill

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patients. Concepts are similar to FCC concepts but more limited in comparison to

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FCC. Identifying family needs is the first step in FCC model implementation,17 but

simply knowing family needs cannot represent the extent to how well the healthcare

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team implemented FCC in the AICU. Since no other Chinese FCC questionnaire was
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developed, we chose the C-CCFNI to validate the newly developed Chinese5-factor

FCCS-AICU. The original English version of the CCFNI was developed by Molter
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(1979) based on crisis and human need theories and revised by Leske (1991).18 The
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45-item, self-reported CCFNI measures needs for support, comfort, information,

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proximity, and assurance. Items are rated on a 4-point Likert-type scale. A higher
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score indicates higher importance of perceived overall needs. The CCFNI was

translated into Chinese and validated by Fan (1996).19 Her study results supported the

C-CCFNI 5-factor structure with Cronbach's α coefficients ranging from 0.52 to 0.77

for subscales and 0.82 for overall scale. In this study with 249 subjects, Cronbach's α

for the subscales ranged from 0.55 to 0.84, with 0.90 overall.

Data Analysis
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Data were analyzed using descriptive and inferential statistics. Statistical analysis was

performed with the Statistical Package for the Social Sciences (SPSS) version 16.0 for

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Windows. Questionnaires with greater than 10% omission were considered

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incomplete and excluded from later analysis. Descriptive statistics were used to

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describe the sample and statistical properties of the subscales. Exploratory factor

analyses (EFA) were used to test construct validity of the Chinese 5-factor

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FCCS-AICU. Pearson correlation (r) was calculated to determine the relationship
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between the Chinese 5-factor FCCS-AICU and the C-CCFNI for convergent validity.

Cronbach's alpha (α) was computed to measure internal consistency.

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Results
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Characteristics of the Sample

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A total of 277 family members of AICU patients were recruited and 28 were excluded

due to more than 10% missing data. Final results were based on 249 subjects. The

demographic characteristics of the 249 subjects are summarized in Table 2. The

majority of subjects were patients' children (41.8%), female (65.56%), and between

35 to 55 years old (51.8%). About 48% of subjects had a college degree or higher.

Eighty-six percent (86%) of subjects visited the hospital by bicycle, motorcycle, or car.
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The average travel time from home to hospital was 28.51 ± 25.13 minutes (range from

2 to 210).

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Exploratory Factor Analysis (EFA)

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Before defining the underlying structure of the 34-item Chinese 5-FCCS-AICU model,

item correlation and item analysis were performed. Tests included test of homogeneity

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and item-total correlation for item analysis.20 Item 1 (feel welcome to be there) was
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deleted due to being highly correlated with item 2 (other family members/I are

welcome) (r = .97). Item 5 (feel like a visitor), item 6 (procedure carried out with
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privacy) and item 22 (overwhelmed by the information given) were deleted due to the
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low Item-Total correlation (r = .15- .28).20

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After deleting these 4 items, an EFA was conducted to evaluate possible underlying
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factors of the 30-item Chinese FCCS-AICU. Prior to the extraction of the factors, the

Kaiser-Meyer-Olkin (KMO) and the Bartlett Test of Sphericity were used to assess the

suitability of the data for factor analysis. The KMO value for the 30-item Chinese

FCCS-AICU was 0.92 and The Bartlett Test of Sphericity chi-square was 3818.84 ( p

< .001), supporting the factorability of the correlation matrix.21 A principal

components analysis with varimax rotation was used to extracted the factors. The

advantage of using PCA is to explain the maximal proportion of the observed

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variance of the data with only a few components. Varimax rotation is a simple

solution to maximize the variance of the item loadings for each factor. Only factors

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that gained an Eigen-value greater than 1 and items with factor loadings above 0.40

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were retained.21 Five factors were extracted from the 30-item Chinese FCCS-AICU,

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which explained 58.34% of the variance. The factors with their respective factor

loadings are presented in Table 3.

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There were 8 items loaded on two factors (both factor loadings > 0.40). After
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evaluating their meaning and significance, all 8 items were retained at their original

designed factors because of clinical relevance. Four other items (2, 7, 18 and 32) were
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not loaded at their original designed factors. After evaluating meaning and
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significance, item 2 (other family members/I are welcome) remained on its original
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designed factor, respect, with an alternate factor loading of 0.37. The other 3 items (7,
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18, and 32) were moved to better suited loading factors. Item 7 (listen to my

thoughts/past experiences) was moved to support, item 18 (flexible visiting hours) to

respect, and item 32 (fully explained the treatment options) to information.

The final factorial structure of the Chinese FCCS-AICU included information (8),

support (7), collaboration (5), empowerment (6), and respect (4). The information

subscale explained 20.43% of the variance, followed by support 13.13%,

collaboration 9.13%, empowerment 8.87%, and respect 6.78%, respectively. The final
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items in each subscale are listed in Table 4, and include item and subscale total mean

scores.

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Convergent validity

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Pearson correlation coefficients were computed to examine convergent validity of the

30-item Chinese FCCS-AICU by comparing it with the C-CCFNI. The total scale of

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the Chinese FCCS-AICU was statistically significantly correlated with the C-CCFNI
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scores (r= 0.46, p <.001).
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Reliability
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The internal consistency of the Chinese FCCS-AICU was evaluated using Cronbach's
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α. Overall internal consistency was 0.93. The internal consistency of subscales were
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as follows, respect 0.58, support 0.87, collaboration 0.71, information 0.90, and

empowerment 0.81.

Discussion

The newly developed Chinese 5-factor FCCS-AICU was found to be a valid and

reliable tool for use with Chinese-speaking family members of AICU patients in

Taiwan. In this study, FCC was hypothesized to be a five-concept construct. These

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concepts are respect, support, collaboration, information, and empowerment. The

hypothesis of FCC with five core concepts was supported by the result of EFA,

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although some items in the subscales were different from the original design.

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Convergent validity established between the Chinese FCCS-AICU and C-CCFNI was

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statistically significant and positively correlated. These two scales only middle

correlated is acceptable because simply knowing family needs ( the C-CCFNI

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measured) cannot represent the extent to how well the healthcare team implemented
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FCC in the AICU (the Chinese FCCS-AICU measured). Internal consistency of the

overall scale was high and Cronbach’s α for the subscales was acceptable.
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This study revealed that information and support were two crucial concepts in FCC,
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accounting for 33.56% of the variance. Information was defined as any updated,
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complete, and unbiased information provided to families on a continuous basis by

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AICU staff.6,9,10 Support was defined as the AICU staff’s acknowledgement of both

patients’ and family members’ needs, and their willingness to listen and communicate

with empathy.6,9,10 This result is consistent with findings from previous Western and

Oriental studies that showed “updated and honest” information and psychosocial

support are important needs reported for ICU family members.11,15,19,22 Aoki et al.

(2008) documented that miscommunication between staff and family members was

the major reason for medical disputes.22 Rothen et al. (2010) indicated that providing
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explicit information can increase family members’ satisfaction.23 In a study done in

Hong Kong, Chien et al (2008) demonstrated that providing psychosocial and

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informational support could reduce anxiety and increase satisfaction of needs among

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Chinese family members of ICU patients.15

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Collaboration is the partnership between patients’ families and healthcare staff. The

staff acknowledged the role of family members in a patient’s life and invited them to

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participate in the patient’s care. Family members reported they felt familiar with the
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AICU staff, were able to participate in their relative’s care, and were prepared for

discharge. This result is supported by a previous study finding6,9,10 that collaboration

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is one of the main concepts in FCC. The positive correlations between collaboration
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with other Chinese FCCS-AICU concepts also is supported Mitchell et al. (2009) who
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found that the greater the level of perceived partnership by family members, the
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greater the overall perceived respect and support.10

Empowerment is defined as family members‘ perceptions that the healthcare staff had

encouraged them to participate in planning patients’ care, and were included in

making decisions. By doing this, the staff can empower family members and enhance

their sense of control, thereby improving their involvement in patients’ care. This

finding supports the results obtained by Paliadelis, et al. (2005) and Hung (2007).11,12
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Hung (2007) reported that Taiwanese family members valued their experiences of

participating in taking care caring for their sick relatives.11

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Respect is defined as the family members’ feelings about being welcomed, being able

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to be with their sick relative whenever they wanted, and having the right to question

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medical treatment. Results of this study indicated that respect was one of the main

factor in FCCS, but the internal consistency value was low. This finding is similar to

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the original 3-factor FCCS-AICU study that also had low internal consistency for
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respect (α = 0.62 with 6 item).10 The other reason for the low internal consistency

value may be related to few items on this subscale. This finding demonstrates that the
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components of respect need to be further developed with more items added. The
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results of this study also showed possible cultural differences in perceptions of respect.
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“Feel like a visitor (item 5)” and “procedure carried out with privacy (item 6)” were
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not significant components of respect, while “Flexible visiting hour (item 18)” was. It

is likely that the findings from studies of western families differ from the experiences

of non-westerners. Western culture emphasizes individual thinking and respect for

individual rights. However, in Oriental cultures individual rights are often of less

importance than group rights.24 Western culture emphasizes the uniqueness of

individuals and the expression of personal feelings, needs, and preferences in

interpersonal relationships. On the other hand, in Oriental cultures, it is not easy to

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express the uniqueness of an individual and personal views. Differences also exist in

the custom of accompanying the patients.11,24,25 In Western countries 10%-25% of

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hospitals do not provide lounges for the family and family members do not expect

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stay with and take care of their sick relative while they are in the hospital.24 They

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come to the hospital to visit at certain times. For Oriental people, if one person is

hospitalized, the whole family is hospitalized.11 Family members want to be with their

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hospitalized sick relative. This custom is challenged when their sick relative is moved
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to the AICU. Even though family members in this study could not stay at the patient’s

bedside, they still wanted to be nearby and ready to provide care at anytime. In most
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circumstances, at least one family member would stay in the hospital lounge for
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24-hours. This may explain why they perceived the “flexible visiting hours” as
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showing “respect” for the family members, because they were allowed to visit their
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sick relative any time they wanted.

Cultural differences may also play a role in what counts as respect versus support in

FCC. Whereas Shelton et al (1995) defined respect as the healthcare staff respecting

the family’s opinions, ideas and past experiences,7 the researchers in this study posited

“listen to my thoughts/past experiences (item 7)” as one element of respect. Results of

this study indicated that Item 7 was loaded on more on support than respect (factor

loading .64 vs. .27). This was supported by Hung’s (2007) qualitative research
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findings11 that family members believed that the health care team who listened to their

past experiences was providing psychological support. Thus, when staff listened to

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families’ expressions of needs and understood them, the Chinese-speaking subjects in

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this study perceived they were receiving psychosocial support from the staff.

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There were limitations to this study that should be noted. First, subjects were recruited

in southern Taiwan. Application of the Chinese FCCS-AICU to other

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Chinese-speaking areas, such as Mainland China, should be evaluated carefully. Due
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to different political and historical backgrounds and dialects, perception of the FCC

construct may be different. Second, the sample was not large enough to compose a
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model derivation and a model validation. The 5-factor Chinese FCCS-AICU was
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developed from the FCCS-AICU and tested in a Chinese-speaking population. Further

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studies are needed to explore validity and reliability of the instrument across different
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cultural groups with a large sample size.

Conclusion

The findings of this study provide initial support for reliability and validity of the

Chinese FCCS-ICU and evidence of cultural relevancy of FCC in a Chinese-speaking

AICU setting. The Chinese FCCS-ICU, measuring family perceptions of the degree to

which the staff provide family-centered care, is a five-construct tool that includes
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respect, support, collaboration, information, and empowerment. The 30-item Chinese

FCCS-AICU questionnaire can be completed within 5-10 minutes with minimal

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burden for the families of AICU patients. The Chinese FCCS-AICU can be used to

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measure the perception of FCC in AICU settings. This tool will benefit healthcare

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providers as they evaluate clinical applicability of FCC in Taiwan.

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References

1. Forsythe P. New practices in the transitional care center improve outcomes for

T
babies and their families. Journal of Perinatology. 1998; 18(6 Pt 2 Su) :S13-7

P
2. Byers JF, Lowman LB, Francis J, et al. A quasi-experimental trial on individualized,

RI
SC
developmentally supportive family-centered care. Journal of Obstetric,

Gynecologic, and Neonatal Nursing. 2006;35(1): 105-115.

NU
3. Ortenstrand A, Westrup B, Broström EB, et al. The Stockholm neonatal family
MA
centered care study: effects on length of stay and infant morbidity. Pediatrics.

2010;125(2):e278-285.
ED

4. Shields L, Pratt J, Davis LM, et al. Family-centered care for children in hospital.
PT

Cochrane Database of Systematic Reviews. 2007;24(1):CD004811.

CE

5. Harrison T M. Family-centered pediatric nursing care: state of the science. Journal

AC

of Pediatric Nursing. 2010; 25(5):335-343.

6. Hutchfield K. Family-centred care: a concept analysis. Journal of Advanced

Nursing. 1999;29(5):1178-1187.

7. Shelton TL, Stepanek JS. Excerpts from family-centered care for children needing

specialized health and developmental services. Pediatric Nursing. 1995;

21(4):362-364.
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8. Shelton TL, Jeppson ES, Johnson BH. Family-Centered Care for Children with

Special Health Care Needs. Washington, D. C : Association for the Care of

T
Children’s Health; 1987.

P
9. Shields L, Tanner A. Pilot study of a tool to investigate perceptions of

RI
SC
family-centered care in different care settings. Pediatric Nursing.

2004;30(3):189-197.

NU
10. Mitchell M, Chaboyer W, Burmeister E, et al. Positive effects of a nursing
MA
intervention on family-centered care in adult critical care. American Journal of

critical care. 2009;18(6):543-552.

ED

11. Hung HL. Parent and Professional Views of Family-Centered Care in the
PT

Pediatric Intensive Care (Chinese). Unpublished thesis. Taipei: National Taipei

CE

College of Nursing; 2007.

AC

12. Paliadelis P, Cruickshank M, Wainohu D, et al. Implementing family-centred care:

an exploration of the beliefs and practices of pediatric nurses. Australian Journal

of Advanced Nursing. 2005;23(1):31-36.

13. Chang, LY. Medicine and Society: an Exploration of Medical Sociology (Chinese).

Taipei: Chuliu Publisher; 2003.

14. Hsieh BS. Medical and Social: Expanding Social Vision of Medical Execution

(Chinese). Taipei: Kingdom Publisher; 2003.

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15. Chien WT, Chiu YL, Lam, LW, Ip, WY. Effects of a needs-based education

programme for family carriers with a relative in an intensive care unit: a

T
quasi-experimental study. International Journal of Nursing Studies. 2006;

P
43:39-50.

RI
SC
16. Wang WL, Lee HL, Fetzer SJ. Challenges and strategies of instrument translation.

Western Journal of Nursing Research. 2006;28(3):310-321.

NU
17. Henneman EA, Cardin S. Family-centered critical care: a practical approach to
MA
making it happen. Critical Care Nurse. 2002;22(6):12-19.

18. Leske JS. Internal psychometric properties of the Critical Care Family Needs
ED

Inventory. Heart and Lung.1991; 20(3):233-244.

PT

19. Fan JY. Family needs in critically head-injured patients and related factors. The
CE

Journal of Nursing Research(Chinese).1996;4(3):273 -284.

AC

20. Chiou HJ. Quantitative Research and Statistical Analysis(Chinese). Taipei :

Wunan; 2009.

21. Wu ML. Structural Equation Modeling (Chinese). Taipei: Wunan; 2008.

22. Aoki N, Uda K, Ohta S, et al. Impact of miscommunication in medical dispute

cases in Japan. Journal of the International Society for Quality in Health Care.

2008; 20(5): 358-362.

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23. Rothen HU, Stricker KH, Heyland DK. Family satisfaction with critical care:

measurements and messages. Current Opinion in Critical Care. 2010; 16(6):

T
623-631.

P
24. Lin ML, Yeh LL, Chen CH. Patient involvement in medical decision making. The

RI
SC
Journal of Nursing. 2009;56(3) :83-87.

25. Vandijck DM, Labeau, SO, Geerinckx CE, et al. An evaluation of family-centered

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care services and organization of visiting policies in Belgian intensive care units: a
MA
multicenter survey. Heart and Lung. 2010; 39(2):137-146.
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Table1 The Original Posted 34 Items of the 5-factor Chinese FCCS-AICU.

Subscale Item Contents
(Item #)
Respect 1. Feel welcome to be there
(7) 2. Other family members/I feel welcome

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3. Be with my relative through procedures

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4. Have a right to question

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5. Feel like a visitor
6. Procedures carried out with privacy

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7. Listen to my thoughts/past experiences

Support 8. Familiar with my relative’s needs

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(6) 9. Listen to my concerns
10. Get to see the same staff
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11. Know my important support people
12. Understand what we went through
13. Concern for my family’s needs
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Collaboration 14. Feel prepared for discharge

(6) 15. Know whom to call
16. Know the primary doctor’s/nurse’s name
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17. Participate in the care of my relative

18. Flexible visiting hours
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19. Discussed care methods

Information 20. Provided honest information a

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(8) 21. Written material easy to understand a

22. Overwhelmed by the given information a
23. Provided orientation
24. Provided updated information
25. Provided similar explanations
26. Explanation is explicit
27. Provided helpful information
Empowerment 28. Was taught how to care a
(7) 29. Included me in decision making a
30. Assessed my care skills/knowledge
31. Encouraged me to participate in care planning
32. Fully explained the treatment options
33. Had the right to participate in the final decision
34. Helped to integrate all the resources
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Note.
FCCS-AICU: Family-Centered Care Survey for Adult Intensive Care Unit.
The items in Italics are new items, and are not in the 3-factor FCCS-AICU.
a
This item was categorized as “collaboration” in the 3-factor FCCS-AICU.

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Table 2 Demographic Information.（N = 249）

Characteristics Frequency %
Sex

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Female 163 65.5

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Male 86 34.5

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Age range

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18-25 31 12.4
26-35 45 18.1

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35-55 129 51.8
56-70 33 13.3
＞71
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11 4.4

Education level
≦ Elementary 27 10.8
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Middle school 27 10.8

High school 76 30.5
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College 98 39.4
≧ Graduate school 21 8.4
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Relationship with patient

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Son/daughter 104 41.8

Spouse/significant other 38 15.3
Others 57 22.9
Parent 31 12.4
Sibling 19 7.6

Transportation
Drive (bike, motorcycle, or car) 216 86.2
Public transportation 19 7.6
Walk 10 4.1
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Table 3 The Exploratory Factor Analysis of the 5-factor Chinese FCCS-AICU (30
items)
Factor Loading
Items Infor Collabo Empow

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-mation Support -ration -erment Respect

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26. Explanation is explicit .804

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24. Provided update information .773
25. Provided similar explanations .759

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27. Provided helpful information .748
20. Provided honest information .667

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32. Fully explained the treatment options .631 .395
23. Provided orientation .616
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19. Discussed care methods .556 .438
21. Written material easy to understand .522
2. Other family members/I feel welcome .479 .373
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13. Concern for my family’s needs .792

12. Understand what we went through .716
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11. Know my important support people .674

9. Listen to my concerns .664
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7. Listen to my thoughts/past experiences .640 .270

8. Familiar with my relative’s needs .472 .519
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10. Get to see the same staff .519 .400

16. Know the primary doctor’s/nurse’s name .609
17. Participate in the care of my relative .583 .441
15. Know whom to call .571
14. Feel prepared for discharge .524
30. Assessed my care skills/knowledge .639
31. Encouraged me to participate in care .434
.624
planning
28. Was taught how to care .468 .624
29. Included me in decision making .469 .575
34. Helped to integrate all the resources .497
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33. Had the right to participate in the final .451

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decision
4. Have a right to question .637
18. Flexible visiting hours .127 .585

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3. Be with my relative through procedures .464

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Eigen value 10.69 2.32 1.85 1.53 1.12

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Explained variance (%) 20.43 13.13 9.13 8.87 6.78
Note. Factor loading < 0.40 not shown, except 4 items (in Bold & Italics) that did not

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load at their original designed factor. Underlined factor loading was considered to
load at that factor.

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Table 4 The Item and Subscale Total Mean Score, and the Cronbach’s α of the final
5-factor Chinese FCCS-AICU (30 items, N = 249).

Subscale Items Item Subscale

(item #) Mean (SD) Total α

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Mean

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(SD)

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Respect 2. Other family members/I feel welcome 3.23 (0.76)
3. Be with my relative through procedures 2.46 (1.03) 12.11 0.58

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(4) 4. Have a right to question 3.49 (0.69) (2.3)
18. Flexible visiting hours 2.93 (0.97)

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Support 7. Listen to my thoughts/past experiences 3.10 (0.85)
8. Familiar with my relative’s needs 3.06 (0.77)
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(7) 9. Listen to my concerns 3.14 (0.78)
10. Get to see the same medical staff 2.96 (0.86) 20.33 0.87
11. Know my important support people 2.46 (0.95) (4.5)
12. Understand what we went through 2.82 (0.92)
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13. Concern for my family’s needs 2.80 (0.87)

Collaboration 14. Feel prepared for discharge 3.10 (0.91)

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15. Know whom to call 3.14 (0.86)

(5) 16. Know the primary doctor’s/nurse’s 3.01 (0.97) 15.80 0.71
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name (3.1)
17. Participate in the care of my relative 3.12 (0.96)
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19. Discussed care methods 3.42 (0.74)

Information 20. Provided honest information 3.42 (0.71)

21. Written material easy to understand 3.17 (0.80)
(8) 23. Provided orientation 3.40 (0.87)
24. Provided updated information 3.28 (0.81) 26.64 0.90
25. Provided similar explanations 3.26 (0.75) (4.7)
26. Explanation is explicit 3.39 (0.70)
27. Provided helpful information 3.37 (0.70)
32. Fully explained the treatment options 3.35 (0.75)

Empowerment 28. Was taught how to care 3.17 (0.91)

29. Included me in decision making 3.17 (0.85)
(6) 30. Assessed my care skills/knowledge 3.02 (0.98) 18.06 0.81
31. Encouraged me to participate in care 3.03 (0.92) (3.86)
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planning
33. Had the right to participate in the final 3.35 (0.75)
decision
34. Helped to integrate all the resources 2.32 (0.95)

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