Intensive and Critical Care Nursing (2010) 26, 114—122

available at www.sciencedirect.com

journal homepage: www.elsevier.com/iccn

ORIGINAL ARTICLE

Supporting families in the ICU: A descriptive

correlational study of informational support,
anxiety, and satisfaction with care
Joanna J. Bailey a,∗, Melanie Sabbagh b, Carmen G. Loiselle c,d,e,f,
Johanne Boileau g, Lynne McVey h,e

a
Adler/Sheiner Patient and Family Support Program, Jewish General Hospital, 3755 Cote-Sainte-Catherine,
D-3322, Montreal, QC, Canada H3T 1E2
b
Maternal/Child Health, Jewish General Hospital, Montreal, QC, Canada
c
McGill University Oncology Nursing Program, QC, Canada
d
CIHR/NCIC Psychosocial Oncology Research Training (PORT) Program, QC, Canada
e
McGill University School of Nursing, QC, Canada
f
Centre for Nursing Research, Jewish General Hospital, Montreal, QC, Canada
g
Division of Cardiology and Critical Care, Jewish General Hospital, Montreal, QC, Canada
h
Jewish General Hospital, Montreal, QC, Canada

Accepted 17 December 2009

KEYWORDS Summary
Information needs; Background: Informational support to family members of ICU patients has significant potential
Anxiety; for reducing their psychological distress, enabling them to better cope and support the patient.
Consumer Objectives: To describe family member perception of informational support, anxiety, satisfac-
satisfaction; tion with care, and their interrelationships, to guide further refinement of a local informational
Critical care; support initiative and its eventual evaluation.
Family centered care Methodology/design: This cross-sectional descriptive correlational pilot study collected data
from a convenience sample of 29 family members using self-report questionnaires.
Setting: 22-bed medical-surgical intensive care unit of a 659-bed university affiliated teaching
hospital in Montreal, Quebec, Canada.
Results: Mean informational support, assessed with a modified version of the CCFNI (Molter and
Leske, 1983), was 55.41(SD = 13.28; theoretical range of 20—80). Mean anxiety, assessed with
the State Anxiety Scale (Spielberger et al., 1983) was 45.41 (SD = 15.27; theoretical range of
20—80). Mean satisfaction with care, assessed using AndrofactTM (Version 4.0, 2001), was 83.09
(SD = 15.49; theoretical range of 24—96). A significant positive correlation was found between
informational support and satisfaction with care (r = 0.741, p < .001). No significant relationships
were noted between informational support and anxiety nor between satisfaction with care and
anxiety.

∗ Corresponding author. Tel.: +1 514 340 8222x1924.

E-mail address: jbailey@nurs.jgh.mcgill.ca (J.J. Bailey).

0964-3397/$ — see front matter © 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.iccn.2009.12.006
Supporting families in the ICU
Conclusion: Findings are related to the ultimate objectives of refining a local informational
support initiative and its eventual evaluation, and in so doing, are of more widespread interest
to others striving to make evidence based improvements to the care of similar populations.
© 2009 Elsevier Ltd. All rights reserved.
Introduction
Attending to the critical, unstable condition of patients who
require intensive care often takes precedence over address-
ing the psychological turmoil experienced by their relatives.
Addressing this psychological distress nonetheless remains
an integral part of a comprehensive critical care approach.
Amidst the high-tech, fast paced environment of the inten-
sive care unit (ICU), family members often play an important
role in promoting the psychological well-being of the criti-
cally ill patient through their familiar and caring presence,
meaningful interaction with the patient, and collaboration
with the treating team in planning care (Burr, 1998). A fam-
ily’s ability to support the patient may become compromised
by their own psychological distress. Anxiety, depression and
even signs and symptoms of post-traumatic stress disor-
der have been documented in this population (McAdam and
Puntillo, 2009). Thus, to promote optimal outcomes for both
patient and family, a vital responsibility of the nurse is to
address the needs and concerns of family members during
ICU hospitalization.
Needs of family members of critically ill patients
The needs of family members of ICU patients have been
studied extensively (Paul and Rattray, 2008) since the semi-
nal work carried out by Molter (1979). Molter’s (1979) early
examination of family members’ needs led to the develop-
ment of the Critical Care Family Needs Inventory (CCFNI,
Molter and Leske, 1983) which has been used in its origi-
nal and adapted forms in much of the research conducted
to date. Family needs are often categorized into 5 domains:
(1) assurance, (2) proximity, (3) comfort, (4) support and, (5)
information (Leske, 1992). The quantitative evidence col-
lected to date has been supplemented to a lesser extent
by qualitative inquiries into relatives’ experience with crit-
ical illness (Agard and Harder, 2007; Burr, 1998; Coulter,
1989; Wilkinson, 1995). Both quantitative and qualitative
investigations, however, have consistently highlighted fam-
ily members’ need for information (Auerbach et al., 2005;
Browning and Warren, 2006; Delva et al., 2002; Verhaeghe
et al., 2005).
Meeting informational needs
Increased interest to develop, implement and test promis-
ing informational interventions for family members of ICU
patients is apparent in the extant ICU literature. For
instance, the implementation of information leaflets for
family members’ orientation to the ICU, its policies, per-
sonnel, and commonly used equipment were found to
significantly improve comprehension of patient diagno-
sis, prognosis and treatment, as well as satisfaction with
information (Azoulay et al., 2002). Individually tailored
needs-based education sessions at admission to ICU were
115
also shown to significantly decrease anxiety and increase
satisfaction (Chien et al., 2006). Supplementing written ori-
entation information with a daily phone call from a patient’s
nurse significantly improved satisfaction with care and per-
ception of having information needs met (Medland and
Ferrans, 1998). Written and verbal communication strate-
gies were also shown to be beneficial in end-of-life contexts
in the ICU, where a brochure on bereavement combined with
proactive communication strategies served to decrease fam-
ily members’ clinically significant symptoms of anxiety and
depression as well as risk of post-traumatic stress disorder
(Lautrette et al., 2007). Evidence provided to date points to
the significant potential contribution of promptly addressing
informational needs in critical care.
Translating research into practice
The interdisciplinary team of our medical-surgical intensive
care unit has long been committed to meeting the informa-
tional needs of their patients’ family members/significant
others, though often finds it challenging to balance these
with the pressing medical needs of patients. Funds from
the hospital foundation and a generous donor provided
the opportunity to address this challenge through imple-
mentation of a support program. Key elements include (1)
renovated physical space to promote families’ privacy, com-
fort and proximity to their ill loved one, (2) improved access
to health information through the development of printed
and interactive health information resources, and (3) the
presence of a full-time consistent clinical nurse special-
ist (CNS) to assist families throughout the crisis of an ICU
hospitalization. The role of the CNS is to complement the
efforts of the interdisciplinary team to ensure each family
obtains, understands, and integrates the information nec-
essary to cope with the critical illness of their loved one,
and to participate in care-related decision making. Indi-
vidually tailored informational support includes orientation
to the critical care environment and team, as well as spe-
cific, timely information about patient condition, care plan,
and prognosis. The CNS maximizes the support available
through three spheres of influence: (1) at the level of the
patient/family through advanced clinical practice, (2) at
the level of nursing and allied health care personnel through
relevant educational/training activities, collaboration and
consultation for complex cases, and (3) at the level of the
organization through support for positive practice changes
to better meet the needs of patients and families experi-
encing critical illness.
Statement of objectives
Supporting and even enhancing family members’ experience
with the potentially life-threatening illness of a loved one
requires a good grasp of many interrelated patient, family,
health care provider and system factors. The present pilot
116
study was conducted to provide a better understanding of
some of these, namely family members’ (a) perceptions of
informational support, (b) anxiety levels and (c) satisfac-
tion with care, and the relationships among these, with the
overarching objectives to further refine the informational
support program and ensuing larger-scale evaluation. The
main hypothesis was that family members with more favor-
able impressions of the informational support offered would
report significantly less anxiety and more satisfaction with
care than those with less favorable impressions of the infor-
mational support offered.
Methodology
Design
A cross-sectional descriptive correlational design was
selected to describe family members’ perceptions of infor-
mational support, anxiety, satisfaction with care and the
interrelationships between these.
Setting
The study took place in the medical-surgical ICU of a uni-
versity affiliated teaching hospital in Montreal, Quebec,
Canada. This publicly funded hospital includes 659 beds,
of which approximately 22 are ICU beds. Patients pre-
senting life-threatening symptoms are admitted directly or
through transfer from all other service areas within the hos-
pital. Elective cardiac surgery patients also are admitted
post-operatively until safely weaned from mechanical ven-
tilation.
Sample
The target sample was family members visiting patients
admitted to the intensive care unit. A convenience sam-
ple was recruited by directly approaching visitors to inquire
about willingness to participate. Based on extensive clini-
cal knowledge of the target sample, inclusion criteria and
patterns of family member visiting, a representative sam-
ple was expected to be accrued despite the convenience
sampling plan.
Participants were selected on the basis of the following
criteria: (1) at least 18 years of age, (2) able to read English
or French, (3) in sufficiently good health to participate, (4)
having a relative/close friend currently hospitalized in the
ICU for at least 24 h. More than one family member per
patient could participate as each member could bring dis-
tinct perceptions of their experience. Family members were
not excluded on the basis of having participated on a previ-
ous admission as their experience may vary greatly from one
admission to another. There were no readmissions, however,
during the study period.
Though a sample size of no less than 30 observations
would have been ideal (Borg and Gall, 1989; Cottrel and
McKenzie, 2005), the study herein sought to obtain pre-
liminary evidence through a pilot study to inform on the
process of accrual, choice of key variables, and statistical
trends. The research team had to contend with challenges
J.J. Bailey et al.
in recruitment that precluded reaching a larger sample
size.
Ethical considerations
The study was approved by both the university’s internal
review board and the hospital’s research ethics commit-
tee. Confidentiality of participants was preserved through
anonymity of the completed questionnaires, not collecting
contact information for the purposes of follow-up proce-
dures, and collecting details pertaining to patients and their
hospitalization from the perspective of the family member
and not the patient record. Initial contact with potential
participants was made by ICU nursing staff who could give
careful consideration to timing, patient condition and emo-
tional state of the family member. Interested participants
subsequently met with the second author, who had no affil-
iation with the ICU, to confirm eligibility, receive additional
information, and complete informed consent. A copy of the
signed consent was provided to each participant, along with
the study questionnaires.
Data collection
Participants received a questionnaire package to complete
in-hospital or at home, to be returned in sealed envelopes
to drop-off boxes located in the ICU family rooms.
Family member and patient characteristics
Family member and patient characteristics were collected
using a self-report questionnaire designed for this study. The
socio-demographic questionnaire included sex, age, educa-
tion level, work status, relationship to the patient, time
spent visiting, previous experience with the ICU, as well as
the ICU patient’s sex, age, and whether the admission was
planned or unexpected.
Informational support
Participants’ perceptions of the informational support
received from the ICU team were measured using a self-
report questionnaire modified from the CCFNI (Molter and
Leske, 1983), with permission from the author (Leske, 2006,
personal communication). The original CCFNI consists of 45
needs statements rated on a 4-point scale ranging from
‘‘not important’’ to ‘‘very important.’’ Test—retest relia-
bility and construct validity of the original inventory have
been demonstrated and internal consistency for the entire
scale is high (˛ = 0.88—0.98 in 5 studies, Molter and Leske,
1991). The CCFNI was modified in two ways for this study.
First, a subset of items addressing informational support
was selected as other domains of family support were not
of relevance to the research objectives. Second, each item
was rated on a 4-point scale ranging from ‘‘never met’’ to
‘‘always met’’ to reflect perception of the informational
support received as opposed to the theoretical importance.
The CCFNI has been modified in this manner for other studies
(Kosco and Warren, 2000; Mendonca and Warren, 1998).
Supporting families in the ICU
Anxiety
Participants’ anxiety was measured using the State-Trait
Anxiety Inventory (STAI) (Spielberger et al., 1983), one of the
most frequently used measures of anxiety in family mem-
bers of ICU patients (McAdam and Puntillo, 2009). The State
Anxiety Scale consists of 20 self-descriptive statements,
rated on a 4-point scale ranging from ‘‘not at all’’ to ‘‘very
much so.’’ The state anxiety index yields a single summa-
tive score where higher scores indicate higher anxiety levels.
Test—retest reliability and construct validity of the STAI have
been demonstrated and internal consistency for the State
Anxiety Scale is high (˛ = 0.92, Spielberger et al., 1983).
Satisfaction with care
Satisfaction with care was measured using a self-report
questionnaire developed by the ICU’s continuous quality
improvement (CQI) team using AndrofactTM (Version 4.0,
2001). AndrofactTM is a satisfaction monitoring system that
assesses, reports, and tracks changes in consumer satis-
faction with healthcare facilities and services. Twenty-four
items addressing various aspects of care were selected from
a bank of 1800 questions, with content validity established
by a panel of experts. Each question asks participants to
rate their satisfaction on a 4-point scale. This measure of
satisfaction was chosen over other instruments designed
specifically for assessing quality of care delivered to fam-
ilies in the ICU (Wall et al., 2007) because it is used by CQI
teams throughout the hospital, thus allowing for benchmark-
ing within and between service areas. The original purpose
for which it was created required that this questionnaire
include several items to address family member satisfaction
with informational support as an important aspect of over-
all satisfaction with care. An objective of the current study
however, was to explore the potential relationship between
perception of informational support and satisfaction with
aspects of care unrelated to information support. Thus,
while the questionnaire was presented to and completed by
participants in its entirety, 9 items addressing informational
support were excluded from the satisfaction with care data
for the purposes of the correlational analysis. Omission of
these items prevented conceptual overlap between infor-
mational support and satisfaction with care measures, thus
permitting exploration of the hypothesis that family mem-
bers with more favorable impressions of informational sup-
port offered would express greater satisfaction with other
unrelated aspects of care in the ICU than those with less
favorable impressions of the informational support offered.
Study instruments were compiled into a package in the
following sequence: (1) STAI, (2) satisfaction with care,
(3) family perception of informational support, and (4) the
socio-demographic questionnaire to minimize the influence
of questions concerning the health care experience on anx-
iety levels.
Data analysis
Data analysis was performed using SPSS (Version 14.0). Fre-
quency distributions were used to present family member
and patient data. To describe family members’ perceptions
117
of informational support and satisfaction with care, item
and total instrument ranges, means, and standard deviations
were computed. To describe family members’ anxiety levels,
mean and standard deviation were computed for the total
sample and by sex. Parametric tests of association (Pearson’s
r) were chosen to test hypotheses regarding relationships
among informational support, anxiety and satisfaction with
care as an adequate sample size and normally distributed
measures were expected and the level of measurement was
of at least interval scale for all variables.
Missing data in the satisfaction with care and the per-
ceived informational support questionnaires were addressed
by computing the average score per item for each partic-
ipant’s scale for which data were missing. This individual
participant average was then inserted for omitted items
for that participant and calculations were subsequently car-
ried out as outlined above. Missing data from the STAI was
managed as per instructions provided in the STAI manual
(Spielberger et al., 1983).
Results
Family member and patient characteristics
Forty-five potential participants were initially approached,
39 of whom consented to participate (refusal rate of 13%).
Of these, 29 returned completed questionnaires (participa-
tion rate of 74%). Participating family members tended to
be female (82.8%), between the ages of 46 and 65 years old
(58.6%), university educated (48.2%) and working full time
(41.4%). They were most often children (44.8%) or spouses
(34.5%) of the ICU patient. Nearly 60% of family members
had no prior experience with the ICU. More than half spent
greater than 5 h/day visiting the patient. Patients tended to
be female (67.9%), and over the age of 66 years old (71.4%).
Both planned (41.4%) and unexpected (58.6%) admissions
were represented in the sample. Family member and patient
characteristics are presented in Tables 1 and 2.
Informational support
Total scores could theoretically range from 20 to 80, with
greater scores indicating greater perceived informational
support. Participants reported total scores ranging from
29 to 80 with a mean of 55.41(SD = 13.28). Informational
support needs most consistently met included having ques-
tions answered honestly, having explanations given that are
understandable and knowing exactly what is being done for
the patient and why. Needs least consistently met included
being told about chaplain services, transfer plans and about
someone who could help with family problems or with
other problems. Informational support data are presented
in Table 3.
Anxiety
Total scores could theoretically range from 20 to 80, with
higher scores indicating greater anxiety. Participants scored
a mean anxiety level of 45.41 (SD = 15.27). Female partic-
ipants scored a mean anxiety level of 46.58 (SD = 16.17).
118 J.J. Bailey et al.

Table 1 Family member characteristics (N = 29). Table 3 Family member perception of informational sup-
port (N = 29).
Variable n %
Item Mean SD
Gender
Female 24 82.8 To have questions answered honestly 3.33 0.78
Male 5 17.2 To have explanations given that are 3.24 0.69
understandable
Age
To know exactly what is being done 3.17 0.76
≤35 years old 3 10.3
for the patient
36—45 years old 4 13.8
To know why things were done for 3.16 0.81
46—55 years old 9 31
the patient
56—65 years old 8 27.6
To have a specific person to call at 3.12 0.96
≥66 years old 5 17.2
the hospital when unable to visit
Highest level of education To know the patient is being treated 3.10 0.77
Secondary school 6 20.7 medically
College 9 31 To receive information about the 3.02 1.02
University 14 48.2 patient at least once a day
Work status To know the expected outcome 2.98 0.81
Full time in paid work force 12 41.4 To know about the types of staff 2.86 0.95
Part time in paid work force 4 13.8 members taking care of the patient
Unemployed 1 3.4 To know specific facts concerning the 2.83 0.97
Disability/Sick leave 1 3.4 patient’s progress
Retired 7 24.1 To have directions about what to do 2.74 1.02
Other 4 13.8 at bedside
To talk to a doctor everyday 2.72 0.93
Relationship to the patient To have explanations of the 2.69 1.06
Spouse 10 34.5 environment before going into the
Child 13 44.8 critical care unit for the first time
Sibling 3 10.3 To know which staff members could 2.67 0.89
Other 3 10.3 give what type of information
Time spent visiting the patient/day To be called at home about changes 2.51 1.23
<1 h 1 3.6 in the patient’s condition
1.5—3 h 6 21.4 To talk to the same nurse everyday 2.38 1.12
3.5—5 h 6 21.4 To be told about other people who 2.37 1.04
>5 h 15 53.6 could help with problems
Missing data 1 To be told about someone who could 2.36 1.10
help with family problems
Previous experience with ICU To be told about transfer plans while 2.32 1.16
Yes 12 41.4 they are being made
No 17 58.6 To be told about Chaplain services 1.83 1.14
Molter and Leske (1983).
Modified with permission from J.S. Leske.
Table 2 Patient characteristics (N = 29).

Variable n %
Male participants scored a mean anxiety level of 39.80
Gender of patient (SD = 8.98). The mean anxiety score in our sample was signif-
Male 9 32.1 icantly higher than the reference values for working adults
Female 19 67.9 (t = 3.511, p < 0.002).
Missing data 1
Age of patient Satisfaction with care
46—55 years old 4 14.3
56—65 years old 4 14.3
Total scores could theoretically range from 24 to 96, with
66—75 years old 13 46.4
higher scores indicating greater satisfaction with care. Par-
76—85 years old 7 25
ticipants’ scores ranged from 58.5 to 96, with a mean of
Missing data 1
83.09 (SD = 15.49). Most satisfactory aspects of care included
Admission to ICU respect of the patient’s dignity, courtesy of the person
Planned 12 41.4 answering the phone and the patient being treated as a
Unexpected 16 58.6 person and not a case by the ICU team. Least satisfactory
Missing data 1 aspects included being encouraged to participate in care
to the degree of one’s comfort, being able to see the doc-
Supporting families in the ICU 119

Table 4 Family member satisfaction with care (N = 29).

Item Mean SD

The patient’s dignity was respected during care and treatment provided by the ICU team 3.86 0.35
When I called the ICU, the person who answered the phone was polite 3.76 0.51
With the ICU team, I felt that the patient was treated like a person and not like a case 3.76 0.64
I was confident with regard to the quality of care provided by the ICU team 3.69 0.47
The visiting hours in the ICU were 3.59 0.57
My first contact with the ICU team was warm 3.59 0.73

a
The ICU team explained the reasons why the patient had to undergo certain tests and 3.59 0.73
examinations
a
I was spoken to in words that I could easily understand 3.57 0.60

The conversations I had with the ICU team on the patient’s state of health were 3.55 0.51
conducted discreetly
During the patient’s ICU stay, the ICU team was attentive to relieving the patient’s 3.53 0.54
discomfort or pain
a
The ICU team explained the reasons why the patient had to undergo certain treatments 3.53 0.73

a
Throughout the patient’s ICU stay, I was informed about the evolution of the patient’s 3.52 0.58
condition
a
The ICU team’s explanations about the patient’s illness were 3.50 0.73
The ICU team was considerate of my concerns 3.48 0.70
a
The ICU team was available to answer my questions 3.43 0.60

The ICU team took my presence into account when they were having personal 3.43 0.52
conversations
Overall, the noise level in the ICU was. 3.41 0.63

a
While the ICU team was carrying out the patient’s treatments, they explained to me 3.39 0.65
what they were doing
a
The ICU team’s explanations about the possible complications related to the treatment 3.34 0.90
were
Our culture, religion, lifestyle and habits were taken into account 3.34 0.59
The ICU team was reassuring about my fears and anxiety 3.33 0.69
a
The ICU team encouraged me to ask questions 3.00 0.85
During the patient’s ICU stay, when I wanted to see the doctor, I could do so 2.99 0.70
The ICU team encouraged me to participate in the patient’s care to the degree that I 2.92 1.01
was comfortable with (for example: mouth care, breathing exercises, etc.)
Questions courtesy of Androfact (2001).
a Questions felt to address informational support and therefore, to converge with the informational support measure, were omitted

from the satisfaction with care data for the purposes of the correlational analyses.

tor when desired and being encouraged to ask questions.
Satisfaction with care data are presented in Table 4.
Correlation between informational support,
anxiety and satisfaction with care
The correlational analysis revealed a significant positive
correlation between informational support and satisfac-
tion with care (r = .741, p < .001). No significant relationship
was found between informational support and anxiety
(r = −0.130, p = 0.502) or satisfaction with care and anxiety
(r = −0.160, p = .406).
Discussion
The present pilot study aimed to describe perceptions of
informational support, anxiety, and satisfaction with care
of family members of ICU patients, and the relationships
among these variables with the ultimate objective of guiding
further refinement of an informational support program and
the research plan for its eventual evaluation. Results are first
discussed in relation to hypothesized relationships between
variables, and subsequently, in relation to refining practice
and future research.
Relationships between informational support,
anxiety and satisfaction with care
It was hypothesized that family members with more favor-
able impressions of the informational support received from
the ICU team would report less anxiety and greater satisfac-
tion with care than those with less favorable impressions of
informational support. Hypothesized relationships between
120
informational support and anxiety, and satisfaction with
care and anxiety were not supported by the results. These
findings diverge from larger-scale studies linking the same
variables (Burr, 1998; Chien et al., 2006; Jamerson et al.,
1996) and suggest that the small convenience sample herein
may not have had the power to detect significant rela-
tionships. Although perceived informational support and
satisfaction with care scores were found to be normally
distributed, anxiety scores were not, making parametric
analyses less defensible than anticipated. An additional pos-
sibility is that measures may not have been sensitive enough
to detect significant relationships in this clinical context.
Examination of anxiety data also raises questions about
these non-significant results. Anxiety in this study’s sample,
while significantly higher than working adults, was not as
high as expected for individuals experiencing the critical ill-
ness of a loved one based on previous studies (Chien et al.,
2006; Delva et al., 2002). Though many factors may poten-
tially explain this, one deserving further consideration is
the high proportion of planned admissions in this sample.
Research suggests that family members of cardiac surgery
patients, which accounts for close to 100% of this ICU’s
planned admissions, experience less anxiety and depression
than family members experiencing unexpected ICU admis-
sions of their loved ones (Young et al., 2005). This may be
related to the well defined processes of information sharing,
both verbally and in writing, pre- and post-operatively that
is the standard of care for this clinical population (Sagehorn
et al., 1999). That this subgroup’s experience likely differs
from family members’ of unexpected ICU admissions sug-
gests the importance of accounting for nature of admission,
and thus of ensuring adequate sample sizes for subgroup
analyses.
The hypothesized relationship between informational
support and satisfaction with care was supported by the sig-
nificant positive correlation found between these variables.
This result was as expected based on the number of previous
studies that have shown the impact of specific information
sharing interventions on family satisfaction (Azoulay et al.,
2002; Chien et al., 2006; Medland and Ferrans, 1998). This
finding supports the potential benefits of timely informa-
tional support interventions, such as the initiative being
developed in this setting, as an avenue for improving sat-
isfaction with other aspects of health care.
Refining practice and future research plans
The clinical significance of this study is highlighted when
considering the ultimate study objectives of refining an
informational support program and future related research.
Results suggest areas of strength to maintain, those to tar-
get for continued development and as seen above, potential
methodological issues to consider before embarking on a
large scale evaluation.
Areas of strength to maintain
Areas of strength in current practice revealed by the data
are briefly discussed here for the benefit of other healthcare
teams aiming to improve the care of similar populations.
Favorably rated elements of informational support and
J.J. Bailey et al.
satisfaction with care such as having questions answered
honestly, being provided with understandable explanations,
feeling the patient’s dignity was respected and feeling that
the patient is treated as a person and not like ‘‘a case’’
are more reflective of a general philosophy of care as
opposed to specific replicable independent practices. This
unit has long been committed to providing patient and fam-
ily centered care (PFCC), an approach to care grounded
in mutually beneficial partnerships between patients, fam-
ilies and healthcare professionals, centered on concepts
of dignity, respect, information sharing, participation and
collaboration (Institute for Family-Centered Care, 2010).
Reviewing all efforts made to advance the understanding
and practice of PFCC in this unit is beyond the scope of this
report but it bears mentioning that these efforts include
implementation and support of the informational support
program. The program’s CNS has continued to reinforce
the unit’s commitment to PFCC through activities such as
role-modeling, emphasizing core concepts of PFCC in con-
sultations with other healthcare professionals, theory and
skill building educational activities for new and experienced
personnel and contributing the patient/family perspective
to interdisciplinary care planning. Efforts such as these to
improve the team’s understanding and practice of PFCC are
likely to have a greater impact on families’ experience of
intensive care then isolated practice changes.
Targets for improvement
Of particular significance to the refinement of the infor-
mational support initiative are the least favorably rated
elements of informational support and aspects of care.
Three of the five least often met informational needs could
be considered part of basic orientation to the ICU; to be
told about chaplain services, to be told about someone who
could help with family problems and to be told about other
people who can help with problems. This type of information
could easily be included in a printed orientation brochure,
and/or included as part of the verbal orientation to the unit
provided by the patient’s nurse at admission. Both strate-
gies have proven effective in improving comprehension of
patient information, increasing satisfaction with care and
decreasing anxiety (Azoulay et al., 2002; Chien et al., 2006;
Medland and Ferrans, 1998). Since completion of this study,
the team has prepared a comprehensive orientation book-
let for families which includes information about resource
persons and chaplain services. With this booklet now in cir-
culation, the next step will be to implement a standard
verbal orientation process to supplement the written mate-
rial.
Family member perception that they were unable to
speak with the same nurse every day, which accurately
reflects the reality of this setting, is another target for
improvement. Primary nursing is not practiced in this set-
ting and thus, patients may never have the same nurse twice
over the course of an ICU stay. It was hoped that the CNS
of the informational support program would help to moder-
ate staffing discontinuity. Family members’ perception that
they cannot speak to the same nurse daily may indicate
that the CNS is not always available to family members on a
daily basis, or that this resource does not address the need
Supporting families in the ICU
for a consistent bedside caregiver. If the wide number of
nurses who care for a given patient cannot be reduced, addi-
tional strategies for ensuring consistency of care planning
and information sharing must be pursued.
Another need reported as being poorly met is to be made
aware of transfer plans as they are unfolding—–a factor which
may be of great significance to anxiety levels. Patients and
families often feel reassured by the one-to-one care and
constant monitoring of the ICU and experience significant
anxiety regarding transfer to a general ward (McKinney and
Melby, 2002; Mitchell et al., 2003). Unfortunately, when
critical care beds are finite resources, patients may be trans-
ferred unexpectedly with little time to share transfer plans
with family members and provide the type of preparation
that may alleviate their anxiety. As transfer anxiety is a
well recognized phenomenon, interventions targeting fam-
ily members’ experience of transfer have received some
consideration in the literature. A structured individualized
transfer method consisting of a printed brochure to prepare
the patient and family for transfer (Mitchell and Courtney,
2004) has been shown to decrease uncertainty levels in fam-
ily members of patients being transferred out of the ICU. The
brochure included transfer plans, ward information, staff
information, and what to expect on the general ward. This
intervention may also lend itself well to the reality of unex-
pected, abrupt transfers.
Another target for improvement is the poorly rated item
of being encouraged to ask questions. As nurse and family
member perceptions of needs are often found to be incon-
gruent (El-Masri and Fox-Wasylyshyn, 2007), encouraging
family members to ask questions ensures that the informa-
tion provided is tailored to their self-identified needs. Daily
tailored information provision, based on family member
needs assessments, has been shown to significantly improve
family satisfaction (Chien et al., 2006). A similar process
could be considered for implementation as part of each
nurse’s daily patient and family assessment.
Encouraging family members to participate in care is
an aspect of care that calls for further attention. Encour-
agement to take part in aspects of patient care has been
reported as both supportive and empowering to family mem-
bers in the ICU, leading to a much needed sense of being able
to do something for the patient (Burr, 1998; Johansson et
al., 2005). Although the study setting has taken large steps
towards a patient and family centered model of care by
opening its doors to unrestricted visiting, there is still some
degree of discomfort with family presence during provision
of care, and with family participation in care giving in partic-
ular, for some nursing personnel. A better understanding of
what underlies this discomfort will be necessary if nurses are
to be expected to encourage family member participation in
care, and this may require consultation and coaching of indi-
vidual nurses as opposed to standard educational/training
sessions.
Future research
As the ICU team continues to refine their practice with fam-
ilies plans to evaluate effectiveness of their efforts should
take the form of a quasi-experimental randomized clini-
cal trial, improve representativeness of the sample through
121
probability sampling and larger sample size, consider a
priori power analyses to ensure a minimum sample size ade-
quate for the statistics chosen and for any subgroup analyses
planned and carefully select validated measures of the vari-
able of interest.
Conclusion
This pilot study began documenting the level and relation-
ships among family members’ perception of informational
support, anxiety and satisfaction with care. At the unit level,
findings provide preliminary data to guide the continued
development and evaluation of informational support ini-
tiatives in the ICU. At the more general level, the pilot data
introduced a potentially meaningful ‘‘grass roots’’ initiative
to improve the informational and psychosocial care of fam-
ily members of critically ill patients. Next steps will include
developing targeted strategies to address areas highlighted
as most in need of improvement and the development of a
rigorous, large scale evaluation of this innovative informa-
tional program.
Conflict of interest statement
No conflict of interests to disclose.
Acknowledgements
The authors would like to gratefully thank the participants
who took the time to contribute to our understanding of
their experience, whilst they were still living through it.
The Intensive Care nurses were invaluable in facilitating
recruitment of these participants, with great sensitivity to
the patients’ physical condition and the family members’
emotional states. We are also indebted to Dr. Celine Geli-
nas for her insightful comments on previous versions of this
manuscript and Paula Calestagne for her assistance with
AndrofactTM . M. Sabbagh, who conducted this study as part
of the requirements for her MSc (A) at the McGill School
of Nursing, would like to thank Nancy Feeley for her sup-
port around study development, as well as Robin Canuel,
medical librarian, and Marie Durand for her assistance with
data management. We also thank Ms. Joelle Berdugo-Adler
for the generous financial support that has allowed for the
development of the informational support program and for
this study to be conducted.Role of funding source: The costs
of questionnaire packages were covered by a donation from
Ms. Joelle Berdugo-Adler, who had no further role in study
design, collection, analysis, interpretation of data, writing
the manuscript, or in the decision to submit for publication.
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