Art & science
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The synthesis of art and science is lived by the nurse in the nursing act
Meeting the needs of patients’
families in intensive care units
Khalaila R (2014) Meeting the needs of patients’ families in intensive care units.
Nursing Standard. 28, 43, 37-44. Date of submission: September 19 2013; date of acceptance: February 25 2014.
Abstract
A review of articles published between 2000 and 2013, retrieved
from several databases, was conducted to identify research findings
regarding nursing interventions intended to meet the needs of the
family members of patients in the intensive care unit. The dimensions
of need identified were support, comfort, reassurance, information and
closeness, with reassurance, information and closeness being the most
important. Overall, the needs of patients’ family members were unmet.
The results of studies revealed that providing families with proactive
communication strategies and information via brochures or leaflets,
developing education programmes and establishing family-centred care
may be effective in increasing family members’ satisfaction, improving
their understanding of the patient’s condition and decreasing anxiety
and depression, and post-traumatic stress disorder. Consequently, nurses
should promote comprehensive family-centred care by using the best
evidence to meet families’ needs. However, more experimental studies
are required to determine the effectiveness of specific interventions.
Author
Rabia Khalaila
Head of nursing department, Zefat Academic College, Zefat 13206, Israel.
Correspondence to: rabeikh@zefat.ac.il
Keywords
Carers, family members, intensive care, intensive care nursing
Review
All articles are subject to external double-blind peer review and
checked for plagiarism using automated software.
Online
Guidelines on writing for publication are available at
www.nursing-standard.co.uk. For related articles visit the archive
and search using the keywords above.
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If you would like to contribute to the Art & science
Josephine G Paterson
ADMISSION OF A relative to the intensive care
unit (ICU) is often unexpected, eliciting negative
psychological symptoms for family members. ICU
admission may cause relatives to feel shock, guilt,
confusion, acute stress, depression, exhaustion,
fear, worry and anxiety (Lee and Lau 2003,
Auerbach et al 2005, Davidson 2009). Factors
associated with such emotions include uncertainty
(Holden et al 2002, Verhaeghe et al 2005), worry
about the care provided by healthcare professionals
(Li 2005), loss of control, unfamiliar environment
(Holden et al 2002), inadequate communication
(Azoulay et al 2000) and the family’s unmet needs
(Lee and Lau 2003).
Nurses have been identified as the professionals
most suited to provide family-centred care
(Lee et al 2000, Browning and Warren 2006,
Al-Mutair et al 2013). Meeting the needs of the
family of ICU patients is likely to lead to better
outcomes for all concerned, including decreased
distress, reduced tension between family and staff,
and more attention being paid by staff to patients’
needs (Lee and Lau 2003). Studies have also
revealed that family members tend to be more
satisfied with the care provided when their needs
are met (Azoulay et al 2002, Auerbach et al 2005).
Mitchell et al (2009) found that involving family
members in the basic care of their loved one may
reduce family anxiety. Basing practice on the best
evidence available has become the standard of care
in the ICU setting (Nelson and Polst 2008).
Therefore, interventions designed to meet family
needs should be a prerequisite for ICU nursing
(De Jong and Beatty 2000).
Studies throughout the world over past decades
have revealed that, although ICU nurses are aware
of family needs, these needs may be forgotten or
underestimated (Holden et al 2002, Verhaeghe
june 25 :: vol 28 no 43 :: 2014 37
Art & science critical care
et al 2005, Obringer et al 2012). This indicates the
need to establish an updated body of knowledge
for ICU nurses about best practice in meeting
family needs in the ICU.
The objective of this review was to identify
effective interventions designed to meet the needs
of families of critically ill adult patients in the ICU.
The conclusions provide recommendations to
clinicians with regard to best practice in this area.
Literature search strategy
A search of ProQuest Nursing & Allied Health
Source, Medline, and Cumulative Index to
Nursing and Allied Health Literature (CINAHL)
was conducted to identify studies published
between 2000 and 2013. The combination
of search terms used were: ‘meeting’, ‘met’,
‘unmet’, ‘needs’, ‘family members’, ‘relatives’,
‘patient’s family’, ‘adult intensive care unit’, ‘ICU’,
‘interventions’, ‘program’, ‘project’, ‘strategies’,
‘guidelines’, ‘recommendations’, ‘effectiveness’,
‘satisfaction’, ‘anxiety’, ‘post-traumatic stress
disorder’ and ‘depression’. The review considered
any randomised controlled trials (RCTs), and
quasi-experimental and English studies that
evaluated the effectiveness of interventions for
families of critically ill patients in an adult intensive
care unit. Articles on quality assurance reports,
paediatrics, organ donations and/or psychiatric
patients were excluded.
Needs of intensive care unit patients’
family members
A growing body of literature is available in which
the needs of ICU patients’ family members are
explored, examining the viewpoints of both
relatives and healthcare professionals (Kosco
and Warren 2000, Bijttebier et al 2001, Kinrade
et al 2010). Most research has used quantitative
methods and Molter’s (1979) Critical Care Family
Needs Inventory, either in its original or translated
form (Appleyard et al 2000, Auerbach et al 2005,
Freitas et al 2007, Hinkle and Fitzpatrick 2011).
However, only a few studies have used the Needs
Met Inventory (Browning and Warren 2006) to
determine frequency of meeting needs (Kosco and
Warren 2000, Lee and Lau 2003, Maxwell et al
2007, Omari 2009).
Five domains of family need have been
consistently identified within the quantitative
studies. These domains are the need for
support, comfort, reassurance, information and
proximity (Lee and Lau 2003, Browning and
Warren 2006, Paul and Rattray 2008, Khalaila
2013). Conversely, qualitative studies have
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identified different domains of need (Takman
and Severinsson 2006, Fry and Warren 2007,
Linnarsson et al 2010). For example, a
meta-synthesis of qualitative research studies
on family needs and experiences generated six
categories of need: uncertainty and emotional
upheaval; information; balancing hope with
reality; the desire to protect and guard one’s
relative; forming an alliance with the caregiver for
crucial support; and the degree of supportiveness
or disequilibrium of the family’s social network
(Linnarsson et al 2010).
Importance of family needs
The importance of family needs from the family
perspective is well documented in the literature.
Most of the literature emphasised that families
need to know about their loved one’s condition
and to be assured that he or she is receiving
high-quality care (Leung et al 2000, Gavaghan
and Carroll 2002). The need for information,
closeness and reassurance were identified as
family priorities frequently and consistently (Lee
and Lau 2003, Chiu et al 2004, Al-Mutair et al
2013, Khalaila 2013), whereas comfort needs and
support needs were the least important (Bijttebier
et al 2001, Holden et al 2002, Verhaeghe et al
2005) (Table 1).
Meeting the needs of family members
Another aspect represented in the literature is the
perception of family needs as having been met.
Several studies examining needs, met and unmet,
showed that healthcare personnel almost always
fail to meet the needs of family members of
critically ill patients (Holden et al 2002,
Verhaeghe et al 2005, Maxwell et al 2007).
According to the literature, this may occur
because ICU nurses and physicians do not perceive
family needs accurately (Davidson 2009, Buckley
and Andrews 2011), or staff fail to support the
family (Obringer et al 2012). Staff also often fail
to recognise how a relative’s active presence in the
ICU may benefit the patient (Azoulay et al 2003,
McAdam et al 2008). Other reasons may relate
to disagreement among healthcare providers
regarding meeting certain needs, such as the
presence of a relative during resuscitation and
other invasive procedures (Al-Mutair et al 2013),
or family presence during ward rounds (Cypress
2012). Lack of time by overburdened care staff
(Bijttebier et al 2001) and poor communication
skills and insufficient training in managing family
needs (Azoulay et al 2000, Holden et al 2002)
were also revealed in the literature.
© NURSING STANDARD / RCN PUBLISHING
TABLE 1
Summary of family members’ perceptions of the importance of needs in different studies
Study Country Five most important needs Five least important needs
Leung et al China To have questions answered honestly. To have a pastoral visit.
(2000) To know the expected outcome. To be told about other people that could help
To know which staff members could give what with problems.
type of information. To be told about someone to help with family
To have information given in understandable terms. problems.
To see the patient frequently. To have a place to be alone while in the hospital.
To be assured it is all right to leave the hospital.
for a while.

Bijttebier Belgium To have questions answered honestly. To have a pastoral visit.

et al (2001) To be assured that the best care possible is being
given to the patient.
To know the expected outcome.
To have information given in understandable terms.
To be called at home about changes in the
patient’s condition.
To be told about chaplain services.
To have good food available in hospital.
To have comfortable furniture in the waiting
room.
To feel it is all right to cry.

Freitas et al Brazil To see the patient frequently. To be told about religious services.
(2007) To feel that hospital personnel care about the To help with the patient’s physical care.
patient. To have comfortable furniture in the waiting
To be told about transfer plans while they are room.
being made. To visit anytime.
To be assured that the best care possible is being To have a place to be alone while in the hospital.
given to the patient.
To know how the patient is being treated
medically.

Omari Jordan To be assured that the best care possible is being To be alone at any time.
(2009) given to the patient. To have a place to be alone while in the hospital.
To feel that the hospital personnel care about the To feel it is all right to cry.
patient. (Only three needs cited)
To feel there is hope.
To have questions answered honestly.
To have the information given in
understandable terms.

Kinrade et al Australia To have questions answered honestly. To be alone at any time.

(2010) To visit any time. To be told about pastoral services.
To be assured that the best care possible is being To have someone be concerned with their health.
given to the patient. To have comfortable furniture in the waiting room.
To know specific facts concerning the patient’s To be encouraged to express emotions.
progress.
To know the expected outcome.

Hinkle and United To be assured that the best care possible is being To have someone to help with financial
Fitzpatrick States given to the patient. problems.
(2011) To know exactly what is being done for the patient. To have a place to be alone while in the hospital.
To have questions answered honestly. To be alone at any time.
To know why things were done for the patient. To talk about negative feelings such as guilt
To feel that the hospital personnel care about or anger.
the patient. To be encouraged to cry.

Khalaila Israel To have the waiting room near the patient. To have explanation of the intensive care unit
(2013) To have visiting hours start on time. environment.
To visit at any time. To feel it is all right to cry.
To have visiting hours changed for specific To have someone to help with financial problems.
conditions. To talk about what happened.
To have questions answered honestly. To have a telephone near the waiting room.

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Art & science critical care

Additionally, the literature demonstrated that
needs most met and least met were inconsistent
in different studies worldwide. While some
scholars found that closeness, information and
assurance needs were most frequently unmet
(Bijttebier et al 2001, Omari 2009, Al-Mutair et
al 2013), others found that reassurance, closeness
and information needs were met most frequently,
with support and comfort needs met least often
(Lee and Lau 2003, Browning and Warren
2006). Other scholars who studied differences
between perceived importance and perceived
needs met, found that mean scores on closeness,
information, comfort and reassurance subscales
were lower for needs met compared with the
importance of needs, mostly referring to the
need for closeness (Khalaila 2013). Nevertheless,
the majority of the researchers agreed that most
unmet needs referred to hospital furniture,
proximity of the waiting room, telephone and
toilet, and ICU policy on visits (Lee and Lau
2003, Browning and Warren 2006, Khalaila
2013) (Table 2).
Interventions used to meet family needs
The nursing literature contains various clinical
practice guidelines and recommendations for
meeting the needs of families in the critical care
setting (Davidson et al 2007, Kynoch et al 2011)
(Box 1). However, several limitations related
to the process of guideline development were

TABLE 2
Summary of family members’ perceptions about the meeting of needs in different studies
Study Country Top five needs that were met most Top five needs that were met least
Kosco and United To have the bathroom near the waiting room. Not cited.
Warren States To know the patient’s prognosis.
(2000) (US) To be assured that the best care possible is being
given to the patient.
To see the patient frequently.
To feel there is hope.
Lee and Lau China To know the expected outcome. To talk to the doctor daily.
(2003) To be called at home about changes in the To visit at any time.
patient’s condition. To help with the patient’s physical care.
To talk to the doctor every day. To feel it is all right to cry.
To be assured that the best care possible is being To talk about negative feelings such as guilt
given to the patient. and anger.
To know how the patient is being treated
medically.
Browning US To know exactly what is being done for the To talk about negative feelings such as guilt
and Warren patient. and anger.
(2006) To know how the patient is being treated To talk about the possibility of the patient’s
medically. death.
To be assured that the best care possible is being To visit the patient at any time.
given to the patient. To speak with the same nurse every day.
To know why things were done for the patient. To have good food available in the hospital.
To know about the type of staff members taking
care of the patient.
Omari Jordan To have someone be concerned with their health. The specific items were not cited in the article.
(2009) To have friends nearby for support. Eleven needs were never met: support (six
To see the patient frequently. items), information (three items), comfort (one
To have another person with you when visiting the item), and proximity (one item).
critical care unit.
To have visiting hours start on time.
Khalaila Israel To be assured that the best care possible is being To be present in the intensive care unit during
(2013) given to the patient. physician rounds.
To have good food available in the hospital. To be present during patient resuscitation.
To have friends nearby for support. To have the waiting room near the patient.
To feel that the hospital personnel care about To have a toilet near the waiting room.
the patient. To have comfortable furniture in the waiting
To know about the type of staff members taking room.
care of the patient.

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identified, including a lack of consultation with
patients and families and a lack of high-level
evidence of results for meeting the needs of
families in the ICU.
Within the literature, six experimental studies
were identified that examined and evaluated
the influence of the recommendations on family
outcomes, such as family satisfaction and
depression (Table 3). These studies included
three RCTs (Azoulay et al 2002, Lautrette et al
2007, Yousefi et al 2012) and three studies with
a quasi-experimental design (Appleyard et al
2000, Chien et al 2006, Mitchell et al 2009).
Of the three RCTs, two examined family
satisfaction as the primary outcome (Azoulay
et al 2002, Yousefi et al 2012), while one
investigated the psychological outcomes of the
interventions, for example, the incidence of
post-traumatic stress disorder (PTSD) and
symptoms of anxiety and depression (Lautrette
et al 2007). Two quasi-experimental studies
investigated the effect on family satisfaction of
interventions to meet the needs of the family in
ICU (Appleyard et al 2000, Chien et al 2006)
and a third quasi-experimental study examined
positive outcomes, such as respect, collaboration
and support (Mitchell et al 2009).
One of the RCTs was performed in 34 French
ICUs and compared family comprehension of
diagnosis, prognosis, treatment, and satisfaction
with information provided by ICU staff. The
families in the intervention group received a
family-information leaflet in addition to standard
information. The results showed that family
members were more satisfied and received more
comprehensive information than the control
group (Azoulay et al 2002). A second RCT
was conducted in a neurosurgery ICU in Iran. In
the intervention group, some interventions, for
example provision of clear explanations, honest
answering of questions, assurances that the
patient was being provided with the best care,
and provision of information regarding the ICU
and its equipment, were performed. In the
control group, only routine actions were carried
out. The results showed that the satisfaction
score significantly increased after the
intervention, as compared to the control group
(Yousefi et al 2012).
Another RCT involved bereaved family
members from 22 ICUs in France (Lautrette
et al 2007). It examined the effect of using
a proactive end of life conference and
a brochure on the psychological outcomes
for families in the ICU. The results showed
that improving communication by using
case conferencing as well as an information
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leaflet decreased the risk of developing
symptoms of PTSD, anxiety and depression
(Lautrette et al 2007).
Additionally, three quasi-experimental
studies reported improved family satisfaction
after intervention (Appleyard et al 2000,
Chien et al 2006, Mitchell et al 2009). One
of these studies investigated the effect of
a needs-based education programme on
family satisfaction and anxiety levels. The
experimental group received a structured
education programme, while the control group
received the ICU nurses’ usual orientation
lecture. Results following the needs-based
intervention reported lower anxiety levels
and greater satisfaction with regards to needs
being met in the experimental group than in
the control group (Chien et al 2006).
Further, pre and post-test design, without a
control group, was used to measure the affect on
family satisfaction at a nurse-coached volunteer
programme in the ICU. Waiting-room volunteers
comforted and supported families, liaising between
ICU nurses and families, acting as an information
resource for referrals and reminding families not to
neglect self-care. The results showed greater family
satisfaction with regard to comfort needs following
the volunteer programme. Furthermore, the
volunteers reported that the nurses became more
communicative and more concerned about families’
needs (Appleyard et al 2000).
Investigators in a third, quasi-experimental
study, examined the effect of family-centred
BOX 1
Potential interventions to meet the needs of family members
 Promote family-centred care.
 Discussion with a nurse on admission.
 Daily or routine meeting or conference between staff and family members.
 Allow family presence during procedures, resuscitation and rounds.
 Allow family members to help with essential patient care.
 Flexible or open visiting hours.
 Structured educational programme for families and nursing staff.
 Family involvement in the decision-making process.
 Use written materials, for example a brochure or personalised
instruction.
 Use technology, for example videotapes or DVDs.
 Support group for family members.
 Provide comfortable and functional waiting rooms close to the unit.
 Use of volunteers to staff the waiting room.
 Refer families for cultural and spiritual support.
 Improve communication.
(Appleyard et al 2000, De Jong and Beatty 2000, Roland et al 2001, Gavaghan
and Carroll 2002, Lee and Lau 2003, Chiu et al 2004, Paul et al 2004, Skelskey
et al 2005, Verhaeghe et al 2005, Chien et al 2006, Miracle 2006, Davidson et al
2007, Gay et al 2009, Nelson et al 2009, Whitcomb et al 2010, Kynoch et al 2011)
june 25 :: vol 28 no 43 :: 2014 41
Art & science critical care

nursing on meeting family needs (Mitchell et al
2009). The experimental group was invited to
assist with some basic care tasks for their relative,
with nurse support, while usual care took place
in the control group. The results revealed that the
nursing intervention of providing family-centred
care improved the respect, collaboration, support
and overall satisfaction scores.
Recommendations for nursing practice
Several recommendations and interventions
have been suggested in the literature to
meet family needs in the ICU environment,
particularly information needs. However,
only a few experimental studies have examined
the effectiveness of these interventions. Some
of the interventions were beneficial for the
family in terms of increasing satisfaction and
reducing anxiety, depression and PTSD.
Further experimental studies, particularly
RCTs, are required to investigate the
effectiveness of interventions for meeting
the needs of the family in the ICU, in particular,
comfort and support needs. However,
healthcare professionals should establish their

TABLE 3
Summary of clinical studies: interventions for meeting the needs of patients’ families in intensive care units
Study Design and sample size Intervention Needs domain Results
Appleyard Quasi-experimental study with Nurse-coached volunteer Five need domains Increased family
et al (2000) pre and post-test design, without programme. of the family: satisfaction from
control group. information, comfort needs only.
Family members = 58. assurance,
closeness,
comfort and
support.
Azoulay A multicentre, prospective, Family-information leaflet. Information Increased family
et al (2002) randomised controlled trial (RCT). needs. satisfaction
Family members (intervention and improved
group = 87, control group = 88). comprehension of
information.
Chien et al Quasi-experimental with pre and Needs-based education Information Reduced anxiety.
(2006) post-test design. programme: the control needs. Increased satisfaction
Family members (control = 32, group received the usual of family members.
experimental group = 34). orientation and explanation;
the experimental group
received an individual
education programme.
Lautrette A multicentre RCT. Using a proactive end of life Information Decreased the risk
et al (2007) Family members (intervention conference and a brochure. needs. of symptoms of
group = 56, control group = 52). post-traumatic stress
disorder, anxiety and
depression.
Mitchell Quasi-experimental with pre and Family-centred care Closeness needs. Improved respect,
et al (2009) post-test design. interventions: at the control collaboration, support
Family members (control = 75, site, patients’ families and overall scores of
intervention = 99). experienced usual care; at the family-centred care.
intervention site, patients’
families were invited to assist
with some of their relative’s
care with nurses’ support.
Yousefi RCT. Nursing interventions based Five need domains Increased satisfaction
et al (2012) Family members (intervention on family needs. of the family: of families.
group = 32, control group = 32). information,
assurance,
closeness,
comfort and
support.

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practice with regard to family needs based on
best evidence available in the literature (Box 2).
Limitations
Specific limitations must be taken into account
in the current review. First, it comprised only
a few experimental studies and, therefore, the
effectiveness of the suggested interventions in terms
of improving family outcomes is not fully known.
Second, as each study used different interventions,
study designs, and outcome measures, it was
difficult to compare studies for each parameter and,
therefore, meta-analysis of results was not possible.
BOX 2
Recommendations for nursing practice
To meet information needs:
 Provide understandable explanations about the disease to the
patient’s family.
 Give honest answers to questions about the patient and the disease.
 Take the family member to the patient’s room and give the necessary
information about the space, equipment, personnel, departments and
actions taken for the patient.
 Allow family members to speak with the patient’s physician.
 Provide information in the form of pamphlets and leaflets in conjunction
with structured meetings.
To meet closeness needs:
 Allow the family to help the patient in some patient care tasks with
nurse support, for example hand and foot massage or feeding.

Conclusion To meet assurance needs:

Studies have shown that family members of ICU
patients have a variety of needs, including that of
support, comfort, reassurance, information and
closeness. The need for reassurance, information
and closeness were identified as the most
important, with comfort and support ranked as
least important.
The Critical Care Family Needs Inventory
emerged as the most common and valid scale to
identify the needs of the ICU patient’s family.
Furthermore, the literature revealed that relatives
and healthcare professionals differed in their
perception of the importance of family needs.
Therefore, it is important that critical care nurses
continue to be aware of, and assess the needs of,
each family member and promote family-centred
care in the ICU as the standard of care NS
 Assure relatives that staff are well trained and are providing the best care.
 Speak about the prognosis of the disease.
 Assure family members that, in their absence, all the patients’ needs
will be met.
 Promise to contact the patient’s family if there is a change in the
patient’s condition.
To meet support needs:
 Give the family the telephone numbers of the hospital and ward (and, if
necessary, the social worker and supervisor).
 Allow the patient’s family members to express their feelings.
 Involve the patient’s family members in new decisions about the patient.
To meet comfort needs:
 Provide families with the location of rest areas, the prayer room,
bathroom and hospital cafeteria.
 Use nurse-coached volunteers to provide comfort for families.
(Appleyard et al 2000, Azoulay et al 2002, Chien et al 2006, Lautrette et al 2007,
Mitchell et al 2009, Yousefi et al 2012)

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