Project 5

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Zila Ben Zaken, MA, RN, is Surgery Clinic Head Nurse, Hadassah Mt. Scopus University Hospital, Jerusalem, Israel. Elena Maoz, MSN, RN, is Faculty Member, Assaf Harofeh Academic School of Nursing, Tzrifin, Israel. Ela Raizman, MPH, RN, is Academic Consulter Nursing Division, Hadassah Mt. Scopus University Hospital, Jerusalem, Israel.

Needs of Relatives of Surgical Patients: Perceptions of

Relatives and Medical Staff

F amily has a central role in maintaining a person’s health and providing informal health

care. It is critical in helping members to manage illness, and in assisting in the recovery and rehabilitation process (Woods & Denton, 2014). The presence of patients’ family members at the bedside constitutes an important source of psychologi- cal stability for the patient, as well as a source of support for better recov- ery (Gillick, 2013; Jezierska, Borkow - ski, & Gaszyński, 2014). Nurses need to understand families’ experiences and identify their needs associated with hospitalization of family mem- bers. This knowledge is essential to optimize families’ well-being and coping as they attempt to provide appropriate, effective support to their critically ill members. The prac- tice of holistic care implies nurses consider needs of patients and their family members (Al Ghabeesh, Abu- Snieneh, Abu-Shahror, Abu-Sneineh, & Alhawamdeh, 2014; Al-Mutair, Plummer, O’Brien, & Clerehan, 2013).

Israel is a multicultural, modern, industrialized state with a strong ethos of mutual support, particular- ly within the family. The extended family is a key social institution, and family members are expected to care for their kin over the life span. This is particularly true in families in the Israeli Arab sector, as well as in families of North African and Asian origin (Bergman, Bodner, & Cohen-Fridel, 2013). Family members stay hours near their loved ones and have reported mul-

tiple emotions, such as anxiety, depression, and fear (Jezierska et al., 2014; Ellis, Gergen, Wohlgemuth, Nolan, & Aslakson, 2016).

The concept of family involve- ment in patient care is an area that has evolved over time, with the focus of nursing care shifting from individual patient care to a family- centered approach (Feinberg, 2014; Hartog & Jensen, 2013) and people- centered health care (Davidson et al., 2017).

Significance of Research Israel is influenced by Western

culture existing together with a Middle-Eastern heritage, including values and practices ranging from highly orthodox religious perspec- tives to secular ways of life with var- ious family lifestyles within differ- ent ethnic and religious groups (Halperin, 2013). Most existing research on the topic of interest was

conducted in Western or Arab countries among family members of patients in intensive care units. Little is known about family mem- bers of patients hospitalized in wards.

Purpose Because of cultural variety of

hospitalized patients, their family members, and the medical staff, the purpose of the study was to investi- gate differences between the per- ceptions of relatives and medical staff concerning the needs of rela- tives visiting patients hospitalized in the surgical intensive care unit (SICU) and surgical wards in an Israeli hospital.

Review of the Literature Manuscripts published 2012-

2017 were screened in a PubMed search using the following terms

Research for PracticeResearch for Practice

Zila Ben Zaken Elena Maoz Ela Raizman

This study investigated perceptions of relatives of patients hospital- ized in surgery ward and surgical intensive care unit and medical staff concerning relatives’ needs. Overall rankings of the needs were similar. Assurance and anxiety reduction emerged as the most important need category.

March-April 2018 • Vol. 27/No. 2 111

(with synonyms and closely related words): needs combined with family, nurse, and CCFNI.

Numerous studies examined per- ceptions of relatives and medical staff (nurses and physicians) of needs of families of critically ill patients using the Critical Care Family Needs Inventory (CCFNI) (Leske, 1991; Molter, 1979). For example, Fortunatti and Felipe (2014) found differences in the order of need scales importance in families of critically ill patients. The family’s hope of desired results and sincere communication with the healthcare staff were the most high- ly ranked needs, while the least important were related to comfort

and support. Sociodemographic and cultural characteristics impact- ed the ranking of individual needs. Most of the studies in general inten- sive care units (ICUs) were conduct- ed in Asia and North America.

Recent original research on the subject was conducted in develop- ing countries and different hospital settings. Obeisat and Hweidi (2014) conducted descriptive research to identify perceived needs of Jordan - ian parents who were visiting their infants in the Neonatal Intensive Care Unit (NICU) using the Family Needs Inventory adapted to NICU setting (N=170). Find ings showed the primary concern of parents was to be assured and informed about

the progress of their infant while mothers’ perceived needs for sup- port, information, and proximity were significantly more important than fath ers’. Hweidi and Al- Shannag (2014) conducted a descriptive study to identify family needs of critically ill adult patients as perceived by nurses working in three critical care units in Jordan (N=65), using the Arabic version of the CCFNI. Nurses ranked the fami- ly need for assurance and informa- tion the highest but indicated the need for proximity as a low priority, a finding different from studies con- ducted in Western cultures.

A study conducted in Iran by Iranmanesh, Sheikhrabori, Sabze - vari, Frozy, and Razban (2014) com- pared the perception of patients’ relatives (n=105) and ICU nurses (n=105). Researchers found the needs for assurance were ranked as the highest and needs for comfort as the lowest priority by nurses as well as by the family. The needs for proximity were perceived a low- order priority and needs for support a higher priority by ICU nurses than families. Shorofi, Jannati, Moghad - dam, and Yazdani-Charati (2016) also compared nurses’ (n=80) and relatives’ (n=80) perception of needs in general, trauma, burn, and car- diac surgical ICUs. Relatives and nurses differed on priority of needs for proximity and support, but needs for assurance were ranked similarly as the highest.

Relatives’ perception concerning the importance of family needs may vary due to influencing factors, such as gender identity, relationship to the patient, and level of educa- tion (Al Ghabeesh et al., 2014; Al Mutair et al., 2013; Iranmanesh et al., 2014). Personal characteristics of healthcare providers were not correlated to ranking needs of rela- tives (Hweidi & Al-Shannag, 2014; Iranmanesh et al., 2014).

Little research has been conduct- ed on needs of families of patients in Israel. Khalaila (2013) studied family satisfaction in meeting needs of relatives of patients in medical intensive care from perspectives of families and staff. No study in Israel has focused on recognizing family

Purpose

Hospitalization of a family member often leaves families feeling vulnera- ble and helpless, with no clear knowledge of what to expect from health- care professionals or regarding patient outcomes. The challenge for nurses is to provide care for ill patients while attending to the needs of stressed family members.

Purpose

Investigate differences between perceptions of relatives and medical staff concerning the needs of relatives of postoperative patients, and explore the influence of relatives’ characteristics on these needs.

Method

Data were gathered at two separate surgery wards and a surgery intensive care unit of a community hospital. Perceived needs of 113 relatives and 45 physicians and nurses were measured using the 45-item Critical Care Family Needs Inventory (Molter, 1979).

Findings

Overall rankings of the needs by the two groups were similar. Assurance and anxiety reduction emerged as the most important factor. Significant differences were found between groups in three areas: information and support categories, and 15 needs items.

Limitations and Implications

Generalization of findings is limited due to use of a convenience sample of non-Western relatives recruited from a single hospital in a unique geo- graphical area. Knowledge about family needs could help nurses plan and implement appropriate early interventions in a more holistic approach to patient care.

Conclusion

Providing information to families of hospitalized patients and assuring them about the quality of care patients receive should be essential com- ponents of a nursing delivery system in postoperative settings.

Needs of Relatives of Surgical Patients: Perceptions of Relatives and Medical Staff

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needs related to cultural and reli- gious values held by family mem- bers and healthcare providers.

Ethics The study was approved by the

Institutional Review Board of the Hadassah University Medical Cen - ter, Jerusalem, Israel.

Sample Selection Hadassah Mt. Scopus University

Hospital, a 300-bed community hospital in Jerusalem, provides medical care to a mix of Jewish and Arab populations. The study was conducted at this hospital on two surgical wards and the SICU located on the same floor as part of ward A. Visitation policy and the level of family involvement in the surgery wards and unit were liberal, with unlimited visitors and open visita- tion 24 hours a day; healthcare pro- fessionals had the option to ask the family to leave the room as needed.

A convenience sample of family members met the following criteria for participation: age 18 or older, marital or blood relative (spouse, adult child, parent, sister, brother), able to read and write Arabic or Hebrew, and visited the ill patient 48 hours after admission to the ICU or ward. All doctors and nurses were invited to participate. The researcher contacted family members at pat - ients’ bedsides when they visited their loved ones. Only one family member participated per patient. When more than one family mem- ber met inclusion criteria, family members identified one among them who would participate. The purpose of the study was explained and informed consent obtained.

Design and Method The CCFNI (Molter, 1979) was

used for this descriptive study. The CCFNI is a self-report questionnaire used in over 50 studies; 45 needs statements appear on a 4-point Likert scale (1=not important, 4=very important). The needs statements are divided into five dimensions: assurance, information, proximity,

comfort, and support. Internal con- sistency of the five dimensions was demonstrated by Cronbach’s alphas of between 0.61 and 0.88, while the Cronbach’s alpha for the total CCFNI was 0.92 (Leske, 1991).

In this study, relatives received the original version of the instru- ment. For medical and nursing staff, items were reworded to assess respondents’ view on relatives’ needs rather than respondents’ self- perceived needs. Items 24 (to have a pastor visit) and 37 (to be told about chaplain services) were changed to “have a religious man visit” and “to be told about religious services” with permission of the tool’s author.

The researcher collected all the instrument packets on the same day as completion by family members so no questionnaires were taken to participants’ homes. Physicians and nurses were asked to complete the questionnaire during their staff meeting. Completed questionnaires were returned in a sealed envelope.

Mean scores on the 45 CCFNI items were ranked in order of impor- tance for each group. Pairwise Spearman’s rank correlations were used to investigate the rankings’ similarity. Mean subscale scores were derived by summing the scores of the items as in the original tool. Between-sample differences were explored through multivariate anal - yses of variance. Relationship to rel- atives’ characteristics were investi- gated by using Pearson correlations to the continuous variable of age and Kruskal Wallis or Wilcoxon- Mann Whitney nonparametric test to the categorical variables of other relatives’ characteristics. The confi- dence level was set at p=0.05.

Findings Characteristics of patients’ rela-

tives and hospital staff are present- ed in Table 1.

Item Scores Overall the rankings by the two

groups were very similar (r=0.925, p<0.0001). The multivariate analy- sis of variance did not reveal an overall group effect (F1, 125=0.304,

p=0.583). Signifi cant group effects were found only for three CCFNI (Molter, 1979) items (6.7%); when “to talk about the possibility of patient’s death” was underestimat- ed while “to have comfortable fur- niture in the waiting room” and “to visit at any time” were overestimat- ed by hospital staff. Family mem- bers and hospital staff perceived 30 of 45 need items on the CCFNI to be very important; each of these items had a mean of 3.0 or higher. None of the items was perceived to be not at all important with means less than 2.0.

The most important need per- ceived by relatives was “to be assured the best possible care is being given.” The next four items, in order of importance, were “to have questions answered honestly,” “to know the expected outcome,” “to feel that hospital personnel care about patient,” and “to know spe- cific facts concerning patient’s progress.” Only “to be assured the best possible care is being given” and “to know the expected out- come” were included in the top five ranking of staff. Staff rated “to know specific facts concerning patient’s progress” as relatively less important (rank 10) and “to know the expected outcome” as more important (rank 1).

The five least important needs for relatives were “to be told about chaplain services,” “to have a reli- gious man visit,” “to be alone at any time,” “to have a telephone near the waiting room,” and “to have someone be concerned with your health.” All items were also the least important needs perceived by staff. Relatives and staff agreed on the rank order of four needs (9%).

Subscale Scores For relatives and staff alike, the

following order of importance of the mean subscale scores emerged: Assurance and Anxiety Reduction, Information, Proximity and Accessi - bility, Comfort, Support (see Table 2). No significant differences emerged be tween subscale ratings of relatives and ratings of hospital staff.

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TABLE 1. Sample Characteristics

Patients’ Relatives N (%)/Mean (SD)

Hospital Staff N (%)/Mean (SD)

Gender Identity Male 47 (41.6) 11 (24.4) Female 66 (58) 34 (75.6)

Religion Jewish 75 (66.3) 38 (84) Muslim 38 (33.7) 7 (16)

Religiosity Secular 48 (42.5) 19 (42.2) Mild religious 24 (21.2) 13 (28.9) Very religious 41 (36.3) 13 (28.9)

Age 45.4 (14.1) 41.1 (10.1) Relationship to Patient

Spouse 43 (38) Adult children 58 (51.4) Other 12 (10.6)

Previous Experience with this Unit or Ward Yes 77 (68.1) No 36 (31.9)

Patient’s Location SICU 39 (34.5) Ward 74 (65.5)

Profession Nurse 35 (78) Physician 10 (22)

Years of Professional Experience ≤5 10 (22.2) 6-10 6 (13.3) 11-15 6 (13.3) 16-20 4 (8.9) ≥21 19 (42.2)

SICU = surgical intensive care unit

Subscale Relatives Staff

Mean (SD) Rank M/Items Mean (SD) Rank M/Items Assurance and anxiety reduction (7 items) 25.56 (2.43) 1 3.65 24.86 (3.26) 1 3.55 Information (9 items) 29.08 (3.83) 2 3.23 29.49 (3.29) 2 3.28 Proximity and accessibility (9 items) 28.36 (4.46) 3 3.15 28.87 (4.41) 3 3.21 Comfort (6 items) 17.99 (3.50) 4 3.0 18.64 (2.70) 4 3.11 Support (14 items) 40.63 (8.58) 5 2.9 39.27 (7.95) 5 2.8

TABLE 2. Mean Subscale Scores

Needs of Relatives of Surgical Patients: Perceptions of Relatives and Medical Staff

March-April 2018 • Vol. 27/No. 2114

Relationship to Relatives’ Characteristics

Age, religion, religiosity, relation- ship to patient, and previous rela- tives’ experience were not related significantly to any need subscales. A significant effect from the rela- tive’s gender identity was found only on need for information (female mean score 28.19 [4.33], male mean score 29.74 [3.36], F=4.16, p=0.044)) and from patient’s place of hospital- ization only on need for support (ward hospitalized mean score 42.16 [8.44], SICU patients’ relatives mean score 37.79 [8.22], relatives F=5.87, p=0 .017). Fifteen individual need items showed a significant dif- ference between various relatives’ characteristics groups (see Table 3).

Discussion This study is the first to describe

the needs of Israeli families of hos- pitalized patients. The findings showed family members could identify needs related to the hospi- tal environment and were able to distinguish relative importance among them. An overall similarity was identified between the needs ratings of relatives and hospital staff. Just two of the five most high- ly ranked needs appeared in both rankings: “to be assured that the best possible care is being given to the patient” and “to know the expected outcome.” These needs are similar to the needs reported by other researchers as most important family needs according to relatives (Al Ghabeesh et al., 2014; Iranma - nesh et al., 2014) and medical staff (Hweidi & Al-Shannag, 2014; Iranmanesh et al., 2014). Other researchers found more similarity between rankings when at least three needs were most highly ranked by both relatives and med- ical staff (Al Ghabeesh et al., 2014; Al-Mutair, Plummer, Clerehan, & O’Brien, 2014).

The items “to be alone at any time,” “to have a telephone near the waiting room,” and “to have someone be concerned with your health” composed the least impor- tant needs for both groups, which is

consistent with other studies (Al Ghabeesh et al., 2014; Iranmanesh et al., 2014). Family members place a low priority on self-care tasks as they attempt to reduce stress and alleviate uncertainty during the cri- sis period. Spiritual consultation belongs to the least important needs in relatives’ self-report as well as medical staff perception, and cannot be considered as a surrogate for the information provided by healthcare workers. The importance of spiritual consultation may increase for relatives once the initial crisis period is over.

Compared to relatives, medical staff assigned a relatively higher pri- ority to only one need “to visit at any time” than relatives did. This probably reflected the reality of con- tinuous presence of family members in Israeli hospitals, even in critical care units. This caused medical staff to appreciate their contribution to hospitalized pa tients.

Seven of the 10 most important needs reported were in the Assurance and Anxiety Reduction sub- scale. The other three were in the Information subscale. All top five needs were related to Assurance and Anxiety Reduction. This finding might indicate the major concern of Jewish and Arab families is the health condition of their hospital- ized relatives. They need to be sure about the prognosis and quality of care received. These findings were consistent with those of others (Al Ghabeesh et al., 2014; Al-Mutair et al., 2014), who found these sub- scales were perceived as important or very important. Families of hospital- ized patients may need information to be certain about the progress of the patient’s condition. The infor- mation may be obtained from healthcare providers or by being with and seeing the patients. Information about the relative and tracking his or her progress was needed to alleviate family members’ stress and uncertainty.

Six of the 10 least important needs identified by family members were listed in the Support subscale. The other four items were listed in the Proximity and Accessibility and Comfort subscales. These findings

were consistent with the findings of other studies conducted with differ- ent cultures (Al Ghabeesh et al., 2014; Al-Mutair et al., 2014). Family members’ concerns were concen- trated on the condition of their loved ones during this period of cri- sis, and they might sacrifice their own needs for support and personal comfort to give time to the health- care team to provide care for their loved ones. In the Arab and East- origin Jewish cultures, families are large and characterized by strong ties among members (Sharabi, 2014). Adult members might partic- ipate in the members’ health care, seeking information or even mak- ing personal decisions. Visiting and providing support to families of sick patients is a social norm practiced by families’ relatives and friends which might decrease their percep- tions of needs for support.

Family needs were not related significantly to most relatives’ char- acteristics. Almost all needs ranked highly important for all relatives, so there was little between-subject variation in the scores. Only need for information was related signifi- cantly to gender identity and need for support to hospitalization in the surgical ward. These findings are consistent with other studies in dif- ferent countries (Fortunatti & Felipe, 2014; Hweidi & Al-Shannag, 2014).

Female subjects rated the needs “to see the patient frequently” and “to visit at any time” as more important than male subjects. Closeness need might be more important in women. Relatives with experience visiting this department perceived items “to know about types of staff members taking care of patient,” “to have visiting hours changed for special conditions,” and “to know specific facts concern- ing patient’s progress” as less impor- tant than those without such expe- rience. Past experience of visiting includes being familiar with depart- ment routine and medical staff, which made items related to those needs less important for them.

This was the first research of ward and ICU together. Family members of ward patients perceived “to talk

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TABLE 3. Mean Differences in Needs Items of Relatives with Demographic Characteristics

Item No. Needs Item

Mean

Z p-Value Gender Identity

Male Female 2(S) Have explanations of environment before going

into 3.27 3.54 4.57 0.035

13(I) Know why things were done for patient 3.43 3.68 4.26 0.041 18(S) Have a place to be alone while in the hospital 2.32 2.97 16.65 <0.001 19(I) Know exactly what is being done for patient 3.34 3.61 4.67 0.033 26(S) Have another person with you when visiting

critical care unit 2.48 2.95 6.93 0.010

38(I) Help with patient’s physical care 2.67 3.09 5.45 0.021 44(P) See patient frequently 3.45 3.61 4.61 0.034

Item No. Needs Item Religion

Z p-ValueJewish Muslim 9(S) Have directions as to what to do at bedside 3.29 2.97 3.97 0.049

Item No. Needs Item Relationship to Patient

Z p-ValueAdult Child Spouse Other 7(S) Talk about feelings about what has happened 2.68 3.22 3.00 4.37 0.015 30(S) Feel it is all right to cry 2.67 3.00 3.50 4.07 0.020 32(C) Have bathroom near waiting room 3.22 2.97 2.50 3.11 0.049 37(I) Be told about religious services 2.02 1.94 2.80 3.28 0.042 44(P) See patient frequently 3.69 3.31 3.10 4.67 0.012

Item No. Needs Item Patient’s Location

Z p-ValueSICU Ward 7(S) Talk about feelings about what has happened 2.65 3.03 2.08 0.038

Item No. Needs Item

Previous Experience with this Unit or Ward

Z p-ValueYes No 6(P) Have visiting hours changed for special

conditions 2.85 3.16 1.99 0.046

15(I) Know about types of staff members taking care of patient

2.88 3.39 2.97 0.003

43(A) Know specific facts concerning patient’s progress 3.23 3.74 2.94 0.003

about feelings about what has hap- pened” as more important than ICU patients’ relatives, who have closer contacts and more discussion with medical staff. Relatives of SICU patients were concerned for the patient’s condition and set aside per- sonal feelings; in the ward, relatives appeared less stressed and more able to recognize their own feelings.

This study found a difference in some needs between children and spouse, or other relatives. “To see

the patient frequently” was more important to patients’ children. Because most of the children visited their parents after being at work, they may have felt guilty in not being able to provide their parents all the care they wanted.

“To have directions as to what to do at the bedside” was ranked by Jewish relatives as more important than by Arabs. Arab families are more conservative regarding gender and family hierarchy differences,

especially out of their home, com- pared to Jewish families (Sharabi, 2014). When their loved ones are hospitalized, cultural differences of relatives become smaller and their needs become universal. Relatives’ needs were independent from reli- gious and religiousness. Researchers were surprised to find no difference in perceived need importance between Muslims and Jews, and sec- ular and orthodox relatives.

Needs of Relatives of Surgical Patients: Perceptions of Relatives and Medical Staff

March-April 2018 • Vol. 27/No. 2116

Limitations Limitations of this study includ-

ed use of a convenience sample from one hospital. Thus, generaliza- tion beyond the sample and geo- graphical area is limited. CCFNI also may lack sensitivity in eliciting needs of Israeli families who might have different beliefs and values than Western families.

Recommendations for Future Research

Studies that use a larger sample and recruit subjects from different settings are recommended to validate the findings. Future research is need- ed to explore difference between per- ceived and met needs of relatives dur- ing patients’ hospitalization. Quali - tative studies can help identity items that may be missing from the CCFNI. Also, research about family members who do not come or cannot come to the hospital would determine if they have the same needs as those includ- ed in the CCFNI.

Nursing Implications Physicians and nurses must be

able to identify needs of family members accurately to meet these needs. Their detection, discussion, and evaluation by the hospital staff can lead to implementation of new policies, such as increased continu- ity in nurse and physician atten- dance and more time spent provid- ing information. This is an impor- tant issue in patient-oriented care and could improve family mem- bers’ satisfaction. Knowledge about family needs could help nurses plan and implement appropriate early interventions according to the importance of these needs, chang- ing the focus to a more holistic approach that includes family needs.

Collaboration should be encour- aged among physicians, nurses, edu- cators, and administrators to meet family needs. Specifically, family need for information about their rel- ative’s condition and prognosis, delivery of information in under- standable terms, and honest and respectful care require special atten-

tion. Nurses’ recognition of families’ needs for information in under- standable language should be an essential element of any counselling or intervention program. Using sim- ple, clear terms and respecting fami- ly members’ knowledge and con- cerns could foster their understand- ing of the patient’s condition and their confidence in the quality of care. Providing updated information to the family, involving them in the patient’s care, and including them in discharge planning might decrease their stress and increase their certain- ty of the patient’s progress.

Conclusion This study provides a scientific

approach to nursing science for hos- pitalized surgery patients and their families in the culturally diverse set- ting of an Israeli hospital. The Assurance and Anxiety Reduction category was identified as the most important need category. The need to be assured the best possible care is being given was identified as the most important need.

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Research for Practice

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