Hospitalization in an Intensive Care Unit (ICU) is a stressing experience not only for the patient, but also for the family. The psycho-social impact that the ICU stay causes due to the vital risk of the family member hospitalized and other potential sources of stress affect the families: a highly technological environment, life support therapies, and the way the healthcare team interacts affects them.1,2 In this setting, the medical literature describes that critically ill patients’ families have specific needs during the ICU stay,3,4 in a more holistic view of the patient and the family, where both are the target of the healthcare that is being provided.5,6 Over the last decade, numerous studies have been published on family needs in the ICU setting being the safety and information needs the most important of all.7

Although it is important to know the needs of the family members,8,9 the medical literature tells us that the healthcare team does not always make an accurate identification of these needs and even when they do, they do not give them the importance they deserve.10 In this sense, Maxwell et al. (2007) revealed that the family members attributed more importance to their needs than nurses did – especially information needs.11 This situation is seen again in other needs such as emotional needs12 and all this translates into healthcare that does not meet the expectations from the family and negatively impacts their satisfaction.

From the healthcare perspective, the user's satisfaction is a priority for the healthcare institutions since it lets us know, first hand, the experience that the individual had with the healthcare received.13 However, at the ICU setting, evaluating this is a little different compared to other clinical units since most patients cannot communicate themselves verbally or give their opinion on the healthcare received. Thus, it is usually the family that has to assess the care, treatment, and attention received14 by their loved ones at the ICU team.

Also, the user's satisfaction is associated with an improved quality in the healthcare received and it depends on the match (or difference) between prior expectations and the perception of the healthcare being received.15 This requires exploring the user's needs16 to determine the difference between the level of importance and the satisfaction of the family needs at the ICU in order to categorize the various needs families have. One of the methods described to analyze the difference between importance and satisfaction of a series of attributes is the importance-performance analysis (IPA).17 Using the IPA methodology in the context of the needs from patients’ families, at the ICU setting, will help the healthcare team identify priority needs and implement interventions when necessary and in a timely manner. The goal of this study was to analyze the difference between the level of importance and the level of satisfaction of the family needs of patients admitted to a teaching hospital ICU.

A total of 253 family members of critically ill patients were included, 70.0% of whom were women, the majority of an age between 30 and 49 years of age (41.1%) being the predominant relationship son/daughter (34.4%). In addition, most of them had the experience of having had a family member hospitalized at an ICU previously (85.0%) and participated in the decision making in connection with their relative's care and treatment (79.8%). 60.3% of the relatives were recruited up to the third day of the patient's stay at the ICU. On this respect, a similar proportion was observed between men and women, being predominantly older than 70 years of age (39.5%). The relatives’ socio-demographic characteristics are shown in Table 1.

As to the difference between satisfaction and importance, it turned out to be negative in 71.1% (n=32) of the family needs, and a greater level of importance than of perceived satisfaction was observed. Table 2 shows that in the dimension of communication, 100% (n=18) of the family needs showed a negative difference, “having a specific person to call the hospital, when you cannot visit the patient” (−0.66), “being called at home if any changes occurred to the relative's condition” (−0.60) and “being able to talk to doctors every day” (−0.42) were among the ones of the biggest magnitude.

In the case of the dimension of support (Table 3), 51.9% (n=14) of the family needs showed a negative difference, and “receiving guidance on what to do at my relative's bedside” (−0.50), “having someone that would help with financial issues” (−0.45) and “visiting your relative at any time” (−0.40), were the ones with the highest value. Compared to the dimension of communication, there was a positive difference in 44.4% (n=12) of the needs.

With respect to the IPA methodology, the cut-off points of the matrix were defined with the median for the level of importance of the needs of the communication dimension equaling 3.74, while for that of satisfaction, it equaled 3.34. In turn, in the dimension of support a median of 3.16 was observed in the degree of importance and 3.03 in that of satisfaction. Fig. 2 shows that most needs of communication concentrated on quadrant B (44.4%), while only “being called at home if any changes occurred to the relative's condition” belonged to quadrant A. Similarly, the support needs (Fig. 3) were grouped preferentially in quadrant B (37.1%), while quadrant A was included the need “speaking about the possibility of your relative's death”, “having someone that would help with financial issues” and “receiving guidance on what to do at my relative's bedside”.

Figure 2.

Diagram of importance – performance for communication needs.

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Figure 3.

Diagram of importance – performance for support needs.

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When it comes to the reliability of the questionnaires, adequate internal consistency was observed both in the original CCFNI version (α=0.91) and in the modified version (α=0.96). Similarly, the dimensions of communication and support obtained high levels of reliability, both in their levels of importance (α=0.82 and 0.89) and satisfaction (α=0.93 and 0.94).

The goal of this study was to analyze the difference between importance and satisfaction in relation to the needs of critically ill patients’ family members. Although it is possible to find studies in the medical literature that have explored both features of family needs,25,26 as far as we know, our study is the first application of the IPA methodology for the analysis of the difference between importance and satisfaction.

The negative difference observed in all the needs of the dimension of communication was determined mainly by the high levels of importance reported by the family members, which is consistent with what has been observed in other studies on the need for information,3,10,27 and contrasts with the low levels of satisfaction. In order to address these differences, it is necessary to incorporate new strategies that would allow optimizing communication between the family and the healthcare team, such as family meetings, participation in clinical rounds, training in communication skills, or the incorporation of a nurse, within the multidisciplinary ICU team, exclusively devoted to the family. These interventions have proven to be able to improve family satisfaction with communication, commitment from the family, and the healthcare personnel self-efficacy.28,29 Additionally, more specific information on how the ICU actually works such as visiting hours, the assignments of each and every member of the team, and common care and therapies could be made available through leaflets or websites, that have already been able to improve understanding diagnoses and procedures, increase satisfaction, and lower the levels of post-traumatic stress in the family members.30,31

The most important negative difference was observed in the need for being called if any changes occurred in the patient's condition, which also turned out to be the only priority need in the dimension of communication. This may be associated with the high level of importance observed, which was considerably greater compared to other studies,2 which, in turn, would contribute to increasing this difference. Although the need to call someone in particular when they could not visit the patient showed the greatest difference of all in the dimension of communication, it is shown in the low priority quadrant.

In the case of the dimension of support, the two needs with the greatest difference of all also turned out to be priorities according to the IPA methodology. The need for receiving guidance on what to do at my relative's bedside would be associated with the family's growing interest in having a more active role in the process of recovery of their loved ones. In this sense, the participation of the family in the basic care of the critically ill patient, such as bathing, oral hygiene, feeding or assistance in the mobilization of the limbs, has proven to have a positive impact on the levels of anxiety, depression, and satisfaction of the family needs, which would help reduce such differences.32,33

In turn, the need for help with respect to financial issues could be explained in the context of the high costs involved in the care and treatment of a patient in critical condition, which is not usually reduced substantially by the local healthcare team. Although the ICU team can be trained to address different family needs, intervention on this particular need would require the management and knowledge of more suitable professionals, such as social workers who, according to the medical literature, not only can cooperate solving the family's financial issues,34 but also provide counseling and psychosocial evaluation, crisis intervention, family training, and support to the ICU members.35 The addition of other professionals with specific, complementary competences will bring the traditional structure of multidisciplinary teams at the ICU to new levels of competence.

The last priority need, speaking about the possibility of their relative's death, was associated with an important negative difference due to a low level of satisfaction that could be explained by different factors. In general, healthcare professionals receive training to maintain health and prevent disease, but training in other aspects is often insufficient, for example, communicating with a patient who is dying and with their family. Also, this could make it difficult to discuss important decisions at the ICU, such as limiting the therapeutic effort.36 Also, that there are cultural and socio-demographic factors, such as beliefs, religion or the geographical area that influence the way the families and professionals make decisions and brief one another on issues that have to do with the end of life.37 In this sense, up to 49% of the patients hospitalized at European ICUs and 25% of those hospitalized in South American make decisions that have to do with suspending or maintaining life-support therapies.38 These elements add to the need for regularly training ICU professionals on effective communication techniques.

When it comes to the tool being used to find out about family needs, the CCFNI is considered to be a valid, reliable tool with suitable psychometric properties.39 However, the 45 items that make up the CCFNI could be a problem in cases where a much larger number of priority attributes were to be observed compared to the number found in this study. Comparatively, the CCFNI has a significantly greater number of attributes compared to other tools used to evaluate the family satisfaction at the ICU, such as the 24-item version of the Family Satisfaction in the Intensive Care Unit or the Critical Care Family Satisfaction Survey – including 20 items. In this sense, the range of the Likert scale associated with the CCFNI (1–4) may not have been broad enough to expose more clearly the differences seen among some of the needs. Also, it is not possible to rule out the fact that a low assessment of some needs may have been associated with the lack of the of the “not applicable” option in the CCFNI. A future validation of the tools that explore these differences should include broader Likert scales with appropriate selection alternatives.

Finally, this study has some limitations, among these the type of sampling used because, since it is not probabilistic, it could have introduced some degree of selection bias. Also, only family members from a single private center were included which means that the interpretation and extrapolation of the results should have been made with caution. On the contrary, among the strengths of the study, we should emphasize here that most studies using the IPA methodology are based on selecting a set of attributes whose validity and reliability have not been confirmed previously. However, in our study, a validated CCFNI version was implemented, which, in addition to the results of internal consistency, increases the reliability of the results obtained. Finally, the sample size used is larger than that of other studies that have assessed importance and family satisfaction at the ICU setting, although without using the IPA methodology.26,27

There is a negative difference between the degrees of importance and satisfaction in the needs from most critically ill patients’ families determined by low satisfaction and high importance, especially in the dimension of communication. The IPA methodology confirmed than only a low percentage of needs should be addressed as a priority, while in a high percentage of those we would be doing a good job. Also, the IPA methodology is a simple tool that allows us to organize the needs and differences of family needs hierarchically facilitating the optimization of the interventions aimed at providing healthcare which would be more consistent with the families’ expectations and requirements at the ICU setting.

This study has been funded by Nursing School Masters Directorate at the Pontifical Catholic University of Chile as part of the contest “Support while elaborating the Nursing master's thesis (APET-2017)”.

CP, NR, and MA participated in the study design. CP conducted the analysis and interpretation of data. CP, NR, and MA collaborated reviewing the manuscript. All authors read and approved the final version of the manuscript.

The authors declare no conflicts of interest whatsoever.