Social Workers' Perspectives on the Psychosocial Needs of Families During Critical Illness

Social Work in Health Care, 50:661–681, 2011Copyright © Taylor & Francis Group, LLCISSN: 0098-1389 print/1541-034X onlineDOI: 10.1080/00981389.2011.590874

Social Workers’ Perspectiveson the Psychosocial Needs of Families

During Critical Illness

TRISH KINRADE, MSW (Hons)Geelong Hospital, Victoria, Australia

ALUN C. JACKSON, PhDMelbourne Graduate School of Education, The University of Melbourne, Australia &

Centre on Behavioural Health, Hong Kong University, Hong Kong

JANE TOMNAY, PhDCentre for Excellence in Rural Sexual Health, Rural Health Academic Centre,

The University of Melbourne, Melbourne, Australia

This article reports the needs of relatives whose family memberis unexpectedly admitted to an Intensive Care Unit. The CriticalCare Family Needs Inventory (CCFNI) was used to measure andrank a series of need statements by family members (n = 25)and social workers (n = 42). Comparative analysis reveals thatthere were need statements that showed a significant difference inmean scores. Minor differences in both the rank order of indivi-dual need statements and the five-factor analysis categories werefound. Implications for clinical social work practice are discussed.

KEYWORDS critical care, family needs, CCFNI

INTRODUCTION

The impact of an admission to an Intensive Care Unit (ICU) is often traumaticfor the family and may result in a crisis within the family. As these eventsdo not occur regularly, individuals are often overwhelmed by their expe-rience of the ICU environment and often consider this encounter to be a

Received December 13, 2010; accepted May 20, 2011.

Address correspondence to Trish Kinrade, MSW (Hons), Senior Social Work Clinician,Geelong Hospital, Ryrie Street, Victoria, 3220 Australia. E-mail: [email protected]

661

662 T. Kinrade et al.

negative one particularly if the outcome is one of severe impairment ordeath (Herman, 1992).

It is not unusual for individual family members to be personally affectedby their experience in the ICU. Their own health and well-being maybe affected by their emotional and psychological experiences of the ICUand the impact can be directly related to the amount of support theyreceive in relation to these needs from staff in ICU. It has previouslybeen established (O’Neill-Norris & Grove, 1986; Lynn-McHale & Bellinger,1988; Chartier & Coutu-Wakulczyk, 1989; Coutu-Wakulczyk & Chartier, 1990;Forrester, Murphy, Price, & Monaghan, 1990; Koller, 1991; Macey & Bouman,1991; Hickey & Leske, 1992; Lee, Chien, & Mackenzie, 2000; Delva, Vanoost,Bijttebier, & Wilmer, 2002; Damboise & Cardin, 2003; Agard & Harder,2007; Eggenberger & Nelms, 2007; Davidson, 2009; Hinkle, Fitzpatrick, &Oskrochi, 2009) that families have some basic needs that must be metby ICU staff in order for them to cope better with the admission oftheir relative to ICU. These needs include (a) information, (b) reassur-ance, (c) support, and (d) the ability to be near the patient (Damboise &Cardin, 2003).

Over the years the issue of understanding family needs has receivedsignificant research attention from the nursing field in particular. Somefour decades after Molter (1979) initially investigated this topic, the issueof understanding family needs still remains important. This article inves-tigates two dimensions to this: (1) family members’ perception of needswhen visiting ICU and (2) social workers’ perception of family needs. Priorto this study, social work had been omitted from the assessment of fam-ily needs within the critical care environment, yet most ICUs have a socialworker supporting the psychosocial and psychological needs of families.This study set out to identify if the perception of family needs held bysocial workers was representative of the current needs of family membersvisiting ICU.

CONCEPTUALIZING AND MEASURING FAMILY NEEDSIN THE CRITICAL CARE SETTING

Critical illness frequently occurs without warning, pushing families beyondwhat is considered the “normal” realm of coping and leading to the expe-rience of trauma and crisis within the family (Daley, 1984). It is wellestablished that hospitalization for a life threatening illness can precipitate acrisis even within the most highly functioning family. Furthermore, unpre-dicted illnesses can require families to renegotiate their established roles inorder to successfully regain their equilibrium (Daley, 1984).

Molter (1979) pioneered research investigating the impact of criticalillness on families following the admission of a family member to ICU. Sheidentified that an unresolved family crisis may in fact affect the outcome for

SW Perspectives on Family Needs During Illness 663

the critically ill patient. As a result of this, Molter (1979) designed a researchtool to answer three key questions:

1. What personal needs do relatives of critically ill patients identify?2. What is the importance of these needs to the relatives? and3. Are these needs being met and if so, by whom?

The resulting Critical Care Family Needs Inventory (CCFNI) utilized 45 need-based questions and focused on determining how family members felt aboutemotional and physical issues and the type of information they required tohelp them understand the care needs of their relative.

Although Leske (1986) was the next notable researcher to continuewith Molter’s (1979) work, Daley (1984) was the next published utilizingthe CCFNI. Daley (1984) set out to determine the immediate needs of fam-ily members with a relative in ICU and to establish which person was mostlikely to meet their specific needs. Daley (1984) identified time factors, a lackof knowledge on how to deal with family members, and a lack of under-standing of how their needs contributes to the client’s situation as issueswhen trying to address overall family needs. She argued that communica-tion with families is generally time limited and focused on factors identifiedas important to nursing staff, not the family.

Leske (1986) investigated the interrelationship of the family and theillness of a family member. As with Molter (1979), Leske (1986) identified theidea that an unresolved family crisis may affect the outcome of the patient’sillness. Leske (1986) argued that given critical illness is often sudden andcomes without warning, there is little time for patients and families to adjustor prepare for the experience that lies ahead of them.

In the years that followed many researchers (O’Neill-Norris & Grove,1986; Lynn-McHale & Bellinger, 1988; Chartier & Coutu-Wakulczyk, 1989;Coutu-Wakulczyk & Chartier, 1990; Forrester et al., 1990; Koller, 1991;Macey & Bouman, 1991; Hickey & Leske, 1992; Lee et al., 2000; Delvaet al., 2002; Damboise & Cardin, 2003; Agard & Harder, 2007; Eggenberger &Nelms, 2007; Davidson, 2009; Hinkle et al., 2009) predominately from thefield of nursing, utilized the CCFNI to undertake research relating to fam-ily needs in intensive care in many countries including the United States,England, Canada, Hong Kong, France, and Holland.

Due to the critical nature of the intensive care environment, the roleof the social worker in this setting diverges from a primary emphasis onreducing length of stay in favor of an emphasis on information provisionand support for patients and family members. Key concepts such as traumaand grief counselling, advocating on behalf of patients and families andcommunicating with patients and families on a level that they understandare all strengths that the social worker can offer. Establishing congruitybetween families’ perceptions of their needs and critical care social workers’perceptions of families’ needs is crucial for effective intervention.


THE SOCIAL WORK ROLE IN CRITICAL CARE

In the intensive care environment, Delva et al. (2002) found that during theinitial 72-hour period following the admission of a patient to ICU, socialwork should be focused on four types of intervention: (1) assessment, (2)providing information, (3) providing emotional support, and (4) helpingto solve practical problems. They further highlight that social work is notprovided 24/7 and that to ensure that adequate support is provided topatients and families, an intervention plan should be designed by the fullmultidisciplinary team to ensure continuity of care for the patient and family.

The role of social workers in intensive care as identified by Delvaet al. (2002) is to provide high risk screening in order to identify and workwith vulnerable family members with the focus on collecting the followinginformation: (a) the high risk factors (facing potential loss, life and death dis-cussions, crisis behavior, etc.); (b) the social and financial condition of thepatient and relatives (presence of multiple psychosocial problems); (c) thepsychological condition of relatives (are they able to cope with the situa-tion?); (d) the availability of functional support, and (e) the perception ofthe event by relatives.

One of the most important times for family members is the initialperiod when the medical and nursing staff advise family members of thepatient’s condition. The social worker at this point ensures that the familyhave a good understanding of the information provided. If the family donot have a good understanding then the social worker should work as alink between the team members. Social workers have the ability to assessthe relatives’ interpretation of the information provided, assess whether thefamily can cope with that information, encourage communication and ques-tioning between everyone involved and ensure that the family understandthe life threatening condition of the patient (Delva et al., 2002). Delva et al.(2002) argued that wherever possible, it is important for the social workerto be present during family meetings to enable them to gain an understand-ing of the patient’s condition and to avoid potential misunderstandings inpatient care. Finally, they argued that through their research, they were ableto derive implications for improved social work practice in ICU. In doingso they found that the provision of assessments, information, emotionalsupport, and solutions to practical problems enabled the social worker toassist family members, and hence indirectly assist patients during their stayin ICU.

AIM OF THIS STUDY

The aim of this study was to provide information relating to the needs offamilies when a relative is unexpectedly admitted as a patient to intensive


care. In order to ascertain this information, the following questions wereconsidered:

● What are the most and least important needs identified by family membersand social workers when a relative is admitted to an ICU?

● What are the similarities/differences between families and social workerswhen ranking identified needs?

● What are the implications for social work clinical practice within the ICU?

METHOD

Sample

All of the family data were collected over a 6-month period in a 16-bedICU at a major regional hospital in Victoria, Australia. Data were collectedfrom family members of patients unexpectedly admitted to the ICU. Dueto generally low numbers of social workers employed to provide a servicein ICU, data were collected through a national survey of social workersproviding any service (i.e., full-time, part-time, or as needed) in either amajor regional or metropolitan hospital in Australia.

Unlike previous studies (Molter, 1979; Daley, 1984; Leske, 1986; O’Neill-Norris & Grove, 1986; Lynn-McHale & Bellinger, 1988; Chartier & Coutu-Wakulczyk, 1989; Delva et al., 2002) in which family members had greatlycircumscribed visiting times, family members at the regional hospital facedno restrictions on visiting hours. As a result of this, it allowed the primaryresearcher, who was also the unit social worker, better access to families andallowed families the opportunity to establish a relationship with staff and theICU environment. The number of visitors at any given time was restrictedto two people; however, an exception was made if all medical support waswithdrawn and death was imminent. Children and/or grandchildren werewelcome to visit their relative at any time as long as a responsible adultaccompanied them.

Instrument

Over the years there has been very little change to the methodology usedwhen implementing the CCFNI in the critical care environment. Molter(1979) completed her research with families once the patient had beentransferred from ICU to the general ward. The question may be asked asto whether the impact of the ICU admission was still fresh to families, as the“crisis” of the situation may have resolved once the patient was transferredto a general ward.

Daley (1984) and Leske (1986) interviewed family members while theirrelative was still in ICU. The time frame for implementation of the CCFNI, as


indicated by previous researchers (Daley, 1984; Leske, 1986; Lynn-McHale &Bellinger, 1988; Forrester et al., 1990; Koller, 1991; Macey & Bouman, 1991;Hickey & Leske, 1992) varied from 24 hours to 6 days following the ICUadmission. On each occasion, however, the patient was still in ICU when theresearcher interviewed family member(s). Although the CCFNI was designedto use a 4-point Likert reporting scale, in some cases, researchers (such asLynn-McHale & Bellinger, 1988) utilized a 5-point Likert scale.

The majority of research to this point has relied on utilizing familymembers over the age of 18 years (and in a few cases the family memberhad to be 21 or older) with no upper age limits set. It was expected that thefamily member had to have visited their relative in ICU, they had to be ableto read to a year 9 level, and they had to be related by blood or marriage.This eligibility criterion has remained stable over the lifetime of the CCFNI.Some of the limitations identified in the previous research include smallnumbers of participants and high numbers of female participants, althoughthis could be reflective of the high number of male patients admitted toICU. Restricted time frames for collecting data (i.e., the researcher may notbe in the ICU when family members are visiting) and the application ofthe data were often relevant to only a small group or small population ofthe community.

Finally, research questions over the years have remained fairly consis-tent with some minor changes in terminology. The key questions utilizedin the research included what do families rate as the most important needsduring this critical time, what needs do they rate as being less important,who meets the identified needs, what are the experiences of family’s, andhow can the quality of their experience be improved?

In the years that followed the work of Molter (1979), Daley (1984),and Leske (1986), many researchers continued to show the value of theCCFNI in assessing the needs of critical care families through an analysisof its psychometric properties. Delva et al. (2002) indicated that the CCFNIhas been regarded as a tool that measures the self-perceived needs of rela-tives of patients hospitalized in ICUs. For the purpose of the current study,“need” has been defined as something inherent in human nature that mustbe fulfilled in order for people to function in everyday life.

As with previous studies, the participants in the current study wereable to identify the importance of each need on the CCFNI. Previousstudies have established readability (Gunning Fox Index = 9.0 = ninth-grade reading level (Macey & Bouman, 1991), reliability (including internalconsistency (Cronbach’s (α) Alpha coefficient of 0.90; Leske, 1991), andtest–retest reliability and overall validity of the CCFNI as a research toolin the intensive care environment. The CCFNI has also been deemed asvalid, reliable, and readable in a number of cross-cultural studies (Coutu-Wakulczyk & Chartier, 1990; Bijttebier et al., 2000; Lee et al., 2000; Agardet al., 2007).


For the purpose of this study, the following changes, suggested byMacey and Bouman (1991) and O’Neil-Norris and Grove (1986), wereutilized based on their assessment of content validity.

Question 24, “To have the pastor visit” and question 37, “To be toldabout chaplain services” were replaced with “To be told about pastoral ser-vices” to remove repetition and to ensure a non-denominational stance wasmaintained. Question 30, “To feel it is all right to cry” was replaced with“To be encouraged to express emotions” thus allowing the option to discussemotions other than crying (i.e., guilt, anger, and frustration). Question 31,“To be told about other people that could help with problems” and ques-tion 34, “To be told about someone to help with family problems” werereplaced with “To be advised of support services who can help with prob-lems” to eliminate repetition. Finally, question 29, “To talk to the samenurse each day” was replaced with “To talk to the nurse caring for myrelative everyday.”

For the purpose of the current study, the following question was added:“To be told the truth even if it is distressing.” Previous research has shownthat families wanted to “feel the need for hope” but at the same time, theywant questions answered honestly. Is it possible for families to feel “hope”if the information they are being given is distressing? Finally, question 6,“To have visiting hours changed for specific conditions” was deleted asthere were no set visiting hours in the hospital ICU where families wereinterviewed.

PROCEDURE

Family Member Recruitment

Two key conditions were implemented to ensure the data collected met thecriteria for the study. First, the patient had to have been unexpectedly admit-ted to intensive care. Second, family members were eligible to participateonce the patient had been in intensive care for at least 48 hours. As withprevious research, the participant had to be related by blood or marriage orbe a close friend of the patient, able to read to year 9 level and aged over18 years with no upper age limit.

Ethics approval was granted by the Human Research Ethics Committeeof the institution in which the research was completed. The researcherinformed the participating family member of the intention, purpose, andprocedure of the research project, provided a plain language statement andwitnessed participants signing the consent form. Confidentiality was guaran-teed and an information pack was provided to the relative at the completionof the informed consent process. The information pack included the plainlanguage statement, a demographic questionnaire ascertaining informationrelating to both the participant and the patient and the CCFNI.


Social Worker Recruitment

Initial contact was made with ICU social workers in metropolitan andregional hospitals across Australia to gather information relating to the totalnumbers of social workers employed in intensive care either full time or parttime and to explain the purpose and procedure of the research. The num-bers of hospitals offering a social work service across Australia are listedin Table 1, together with the number of social workers employed in theICU. Seventy-eight hospitals across Australia were identified as providing anICU social work service of some type. Information packs including the planlanguage statement, CCFNI, and consent form were distributed as per thenumber of social workers employed in ICU as identified in Table 1.

FINDINGS

The following analysis was based on a participation rate of 78% (25/32)for families and 35% (42/120) for social workers. The return rates reflectthe immediacy of the recruitment process. The unsolicited mailout is lowerin response rate than the family response rate with whom the primaryresearcher met in person; however, the unsolicited rate was appropriateas it gave a spread of social work responses across Australia. Social workersin Queensland, Northern Territory, New South Wales, Victoria, and Tasmaniareturned questionnaires.

Sociodemographic Information

Data were collected from the family members of 25 critically ill patients whohad been unexpectedly admitted to the hospital’s ICU. During this perioda total of 138 patients were unexpectedly admitted to ICU for treatment.This included 47 emergency surgical patients and 91 medical patients. Thenumber of family members invited to participate represented 24% of the

TABLE 1 Summary of ICU and Number of Social Workers Employed Across Australia

State

Number ofmetropolitanhospitals with

ICU

Number ofsocial workers

in ICU

Number ofregional/ruralhospitals with

ICU

Number ofsocial workers

in ICU

Victoria 21 46 8 9Tasmania 3 3 0 0Northern Territory 2 2 0 0South Australia 3 3 0 0Western Australia 5 7 3 5Queensland 10 17 4 5New South Wales 11 15 8 8Total 55 93 23 27


TABLE 2 Characteristics of Patients Admitted to ICU WhoParticipated in This Study

Reason for admission

Respiratory Distress/Arrest 6 (24%)Emergency Surgery (general) 3 (12%)Pancreatitis 3 (12%)Emergency Cardiac Surgery 2 (8%)Motor Vehicle Accident 2 (8%)Acute Renal Failure 2 (8%)Did not specify 2 (8%)Endocarditis 1 (4%)Blocked Epiglottis 1 (4%)Chronic Renal Failure With Sepsis 1 (4%)Cancer of the Bowel 1 (4%)Ketoacidosis 1 (4%)Total 25 (100%)

total patients admitted and the number of respondents represented 18% ofthe total patients admitted. However, not all of the patients admitted met thecriteria for participation; that is, some patients did not stay in ICU for longerthen 48 hours. Table 2 illustrates the characteristics of patients admitted toICU and included in the study.

Table 3 shows that there was an uneven spread across the sexes forparticipants. The relationship to the patient included spouses, mothers, and

TABLE 3 Characteristics of Family Members(N = 25)

GenderMale 3 (12%)Female 22 (88%)

Age18–33 034–39 12 (48%)40–65 8 (32%)66–70 1 (4%)71+ 4 (16%)

Relationship to patientSpouse 9 (36%)Child 9 (36%)Parent 5 (20%)Daughter in law 1 (4%)Friend 1 (4%)

Highest academic qualificationPrimary school 2 (8%)Secondary school year 8 2 (8%)Secondary school year 9 4 (16%)Secondary school year 10 4 (16%)Secondary school year 11 1 (4%)Secondary school year 12 1 (4%)Undergraduate 21 (4%)Postgraduate 3 (12%)


TABLE 4 Professional Characteristics of SocialWorker Participants (N = 42)

ICU employment statusPart time 14 (33%)Full time 8 (19%)ICU work as part of other duties 20 (48%)

Employment levelGrade 1 4 (10%)Grade 2 22 (52%)Grade 3 13 (31%)Welfare worker 3 (7%)

Years of experience in social workMean 11.0Median 6.5

Years of experience in ICU socialworkMean 4.2Median 3.5

ICU levelLevel 1 5 (12%)Level 2 9 (21%)Level 3 16 (38%)Not specified 12 (29%)

ICU specialties∗

Orthopaedic Trauma 23Musculoskeletal Trauma 21Obstetric Trauma 11Paediatric Trauma 10Neuro Trauma 23Spinal Trauma 13Burns 14General 4Not Specified 8

Number of patients in a 12-monthperiodMean 770Not specified 20

∗An ICU may offer more then one specialty; hence thelarge number of specialities in comparison to the numberof participating social workers.

friends while the age of the participants ranged from 34 to 71+ years withthe majority falling into the age range of 34–65 years. Academic qualificationsvaried from primary school to a University Masters degree.

Data were collected from 42 social workers employed in ICUs aroundAustralia (Table 4). Employment status varied from being full time in theICU to a shared caseload with other hospital wards. The position held bythe social workers during this study ranged from less experienced grade 1to clinical specialist grade 3 social workers. Years of experience in the fieldof social work ranged from 10 months to 25 years while years of social workexperience in the ICU environment ranged from 3 months to 15 years. Thesocial workers varied in their ranking of their ICU as level I, II, or III and a


variety of specialist services provided at major regional and country hospitalsacross Australia were listed. Finally, the social workers estimated the totalnumber of patients unexpectedly admitted to their ICU in a 12-month periodranging from 110 to 1,100.

Item Analysis for the CCFNI

Item analysis was completed for both of the groups with each being askedto rank each question from the CCFNI based on a Likert scale of 1 notimportant, 2 slightly important, 3 important, and 4 very important. Themeans and standard deviations for the 43 questions in the CCFNI werecalculated for families and social workers.

Most and Least Important Needs per Group

The need identified as being of the highest importance to both groups was“to have questions answered honestly.” Previous research had establishedthat “to feel there is hope” was the most important ranked need for familymembers. Analysis of this question resulted in a mean difference being iden-tified between family and social workers (t = –2.344, p = .000, df = 65);however, the result is not considered meaningful as both groups ranked theneed in the important to very important category.

While families ranked 77% of the total need statements in the rangeof 3.00–4.00, it is important to understand what they feel are insignificantneeds during the ICU admission. The majority of the lower ranked needs arethose that pertain to family members’ own personal requirements. Table 7illustrates the five least important needs as identified by both of the partic-ipating groups. A comparison with previous studies demonstrates that, aswith Molter’s (1979) research, family members want the ICU staffs’ atten-tion focused on the patient’s care and not on their personal needs. Whileit is important for the doctors and nurses to maintain their attention on thepatient, the social worker has an opportunity to address the aforementionedissues without the family feeling as though the focus on the patient has beendiminished.

Social workers ranked the need “to help with the patient’s physical care”as a less important need while the family ranked it in the more important3.00+ range. For families, assisting with the physical care of the patientallows them to maintain contact in a very personal way. Allowing familymembers to assist with washing the patient or massaging their arms, legs,hands, and feet provides them with a purpose at the bedside and removesthe notion that they are simply in the way of the staff who are caring fortheir relative.

Social workers identified the need “to have a specific person to callwhen unable to visit in person” as lower in importance than family members


who ranked it in the 3.00+ range. This is reflective of social workers’ under-standing of how staff allocation in ICU works. They are aware that differentstaff members care for the patient not only on different days and but alsoat different times during the same day. As such, it is very difficult to call aspecific person to obtain up-to-date information about the patient.

As was previously noted, family members ranked 77% of all needs itemsin the important to most important range of 3.00–4.00. In comparison, socialworkers ranked 86% of all needs items in the more important range. Table 8utilizes the data in Table 5 to list the results of a comparison between thetwo groups where the identified needs were ranked in the not important toslightly important categories by at least one of the groups.

The comparison of the ranked means is important as it demonstratesthe compatibility of ranking in terms of importance across both groups.Given that the social work data were collected from across Australia, thisresult also demonstrates an understanding of family needs in the criticalcare environment from a broad clinical perspective rather than a perspectivedetermined by specific organizational practices and cultures.

A number of questions were identified as producing a statistically dif-ferent mean value between the social workers and family including thefollowing five questions:

Question 9, “To visit at any time” (t = –3.048, p = .000, df = 65).Questions 13, “To feel there is hope” (t = –2.344, p = .000, df = 65).Question 15, “To know about the types of staff members taking care of the

patient” (t = –2.344, p = .001, df = 65).Question 29, “To be encouraged to express emotions” (t = 3.549, p = .001,

df = 65).Question 41, “To know specific facts concerning the patient’s progress”

(t = –2.366, p = .001, df = 65).

In summary, the results illustrate a need by families, which is supportedby social workers “to have questions answered honestly.” Families also need“to visit the patient at any time” and “to know the expected outcome.” Theinteresting point was that the family group did not rank “to be told the trutheven if it is distressing” with high importance whereas social workers feltthis was very important. Social workers also felt that explanations neededto be given in terms that were understandable to the family without con-taining medical “jargon”; however, the family did not recognize this as animportant need (Table 6).

Original CCFNI Factor Analysis

The original factor analysis of the CCFNI produced five clusters of needincluding the need for information, assurance and anxiety reduction,


TABLE 5 CCFNI Item Means and Standard Deviations per Sub Group

Family (N = 25)Social workers

(N = 42)

Question Mean SD∗ Mean SD∗

1. To know the expected outcome. 3.84 .374 3.67 .5262. To have explanations of the environment

before going into the critical care unit for thefirst time.

3.28 .678 3.40 .587

3. To talk to the doctor every day. 3.60 .645 3.57 .5904. To have a specific person to call at the

hospital when unable to visit.3.04 .978 2.88 .803

5. To have questions answered honestly. 4.00 .000 3.93 .2616. To talk about feelings about what has

happened.3.12 .881 3.62 .492

7. To have good food available at the hospital. 3.16 .943 2.74 .7678. To have directions as to what to do at the

bedside.3.00 .866 3.24 .532

9. To visit at any time. 3.88 .440 3.40 .70110. To know which staff members could give

what type of information.3.28 .792 3.24 .576

11. To have friends nearby for support. 3.20 .866 3.33 .61212. To know why things were done for the

patient.3.72 .542 3.60 .544

13. To feel there is hope. 3.80 .408 3.45 .67014. To be told the truth even if it is distressing. 3.68 .690 3.81 .39715. To know about the types of staff members

taking care of the patient.2.88 1.054 3.12 .670

16. To know how the patient is being treatedmedically.

3.64 .569 3.71 .457

17. To be assured that the best care possible isbeing given to the patient.

3.80 .577 3.81 .397

18. To have a place to be alone while in thehospital.

2.60 1.118 3.07 .867

19. To know exactly what is being done for thepatient.

3.72 .458 3.55 .670

20. To have comfortable furniture in the waitingroom.

2.68 .802 2.90 .759

21. To feel accepted by hospital staff. 3.60 .500 3.38 .73122. To have someone to help with financial

problems.2.84 .898 3.02 .643

23. To have a telephone near the waiting room. 3.00 .978 3.45 .63324. To talk about the possibility of death. 3.52 .918 3.38 .58225. To have another person with you when

visiting the critical care unit.2.84 1.068 2.76 .726

26. To have someone be concerned with yourhealth.

2.56 1.003 2.81 .773

27. To be assured it is alright to leave thehospital for awhile.

2.96 1.060 3.31 .680

28. To talk to the nurse caring for my relativeeveryday.

3.68 .557 3.57 .590

29. To be encouraged to express emotions. 2.68 .998 3.36 .57730. To have a bathroom near the waiting room. 3.00 .913 3.19 .594

(Continued)


TABLE 5 (Continued)

Family (N = 25)Social workers

(N = 42)

Question Mean SD∗ Mean SD∗

31. To be alone at any time. 2.12 1.013 3.02 .75832. To be advised of support services who can

help with problems.3.52 .653 3.45 .633

33. To have explanations given that areunderstandable.

3.80 .500 3.88 .328

34. To have visiting hours start on time. 3.13 1.076 3.32 .85035. To be told about pastoral services. 2.28 .936 3.05 .77336. To help with the patient’s physical care. 3.24 .723 2.67 .78637. To be told about transfer plans while they

are being made.3.60 .500 3.62 .539

38. To be called at home about changes in thepatient’s condition.

3.80 .408 3.86 .354

39. To receive information about the patientat least once a day.

3.64 .569 3.62 .623

40. To feel that the hospital personnel care aboutthe patient.

3.88 .332 3.81 .397

41. To know specific facts concerning thepatient’s progress.

3.88 .332 3.60 .544

42. To see the patient frequently. 3.84 .374 3.67 .57043. To have the waiting room near the patient. 3.24 1.052 3.40 .767

∗SD = Standard deviation.

TABLE 6 Five Most Important Needs as Identified by Social Workers (SW) and FamilyMembers (FAM)

Question Description SW Mˆ(SD)∗ FAM Mˆ(SD)∗

5 To have questions answered honestly. 3.93 (.261) 4.00 (.000)9 To visit at any time. — 3.88 (.440)

40 To feel that the hospital personnel care aboutthe patient.

3.81 (.397) 3.88 (.332)

41 To know specific facts concerning thepatient’s progress.

— 3.88 (.332)

1 To know the expected outcome. — 3.84 (.374)42 To see the patient frequently. — 3.84 (.374)17 To be assured that the best care possible

is being given to the patient.— —

14 To be told the truth even if it is distressing. 3.81 (.397) —33 To have explanations given that are

understandable.3.88 (.328) —

38 To be called at home about changes in thepatient’s condition.

3.86 (.354) —

ˆMean; ∗Standard deviation.

proximity and accessibility, support and comfort. Analysis of data based onfactor categories previously established by Leske (1986) was undertaken.Both groups ranked “Need for Assurance and Anxiety Reduction” as the


TABLE 7 Five Least Important Needs as Identified by Social Workers (SW) and FamilyMembers (FAM)

Question Description SW Mˆ(SD)∗ FAM Mˆ(SD)∗

31 To be alone at any time. — 2.12 (1.013)35 To be told about pastoral services. — 2.28 (.936)26 To have someone be concerned with your

health.2.81 (.773) 2.56 (1.003)

20 To have comfortable furniture in the waitingroom.

— 2.68 (.802)

29 To be encouraged to express emotions. — 2.68 (.988)7 To have good food available at the hospital. 2.74 (.767) —4 To have a specific person to call at the hospital

when unable to visit.2.88 (.803) —

36 To help with the patient’s physical care. 2.67 (.786) —15 To know about the types of staff members

taking care of the patient.— —

25 To have another person with you when visitingthe critical care unit.

2.76 (.726) —

ˆMean; ∗Standard deviation.

TABLE 8 Not Important to Slightly Important Needs

To have a specific person to call at the hospital when unable to visit (SW)To have good food available at the hospital (SW)To know about the types of staff members taking care of the patient (F)To have a place to be alone while in the hospital (F)To have someone to help with financial problems (F)To be assured it is alright to leave the hospital for a while (F)To be encouraged to express emotions (F)To be alone at any time (F)To be told about pastoral services (F)To help with the patients physical care (SW)

TABLE 9 Factor Analysis Mean Scores and Ranked Results per Group

Factor group Family Social workers

Need for information 3.48 (2) 3.45 (2)Need for assurance & anxiety reduction 3.53 (1) 3.62 (1)Need for proximity & accessibility 3.39 (3) 3.42 (3)Need for support 3.10 (5) 3.21 (5)Need for comfort 3.25 (4) 3.33 (4)

most important factor category. Needs such as to feel there is hope, tohave explanations given that are understandable, and to know specific factsconcerning the patient’s progress feature in this factor group. The overallrank order for family and social workers was identical when utilizing the fulldata set (Table 9).

The use of demographic data enabled the division of the originaldata set into subgroups. The main group of family was divided into four


TABLE 10 Factor Analysis Mean Scores and Ranked Results per Relative Subgroups

Factor group Spouse Parent Child Other

Need for information 3.43 (2) 3.36 (2) 3.52 (2) 3.78 (1)Need for assurance & anxiety reduction 3.54 (1) 3.57 (1) 3.56 (1) 3.43 (4)Need for proximity & accessibility 3.35 (3) 3.34 (3) 3.40 (3) 3.64 (2)Need for support 2.99 (5) 2.99 (5) 3.25 (4) 3.39 (5)Need for comfort 3.24 (4) 3.17 (4) 3.22 (5) 3.58 (3)

TABLE 11 Factor Analysis Mean Score and Ranked Results of Social Workers by Yearsof Experience

Factor groupUnder 5 y in

ICUOver 5 y in

ICUUnder 5 y insocial work

Over 5 y insocial work

Need for information 3.49 (2) 3.38 (3) 3.50 (2) 3.42 (2)Need for assurance &

anxiety reduction3.59 (1) 3.69 (1) 3.58 (1) 3.65 (1)

Need for proximity &accessibility

3.42 (3) 3.41 (2) 3.44 (3) 3.40 (3)

Need for support 3.23 (5) 3.17 (5) 3.24 (5) 3.19 (5)Need for comfort 3.32 (4) 3.37 (4) 3.29 (4) 3.37 (4)

subgroups including “spouse” (wife, husband and partner), “parent” (includ-ing mother and father), “child” (including children by birth only), and“other” (including family by marriage and friends). Table 10 shows that both“spouse” and “parent” groups ranked the factors in the same order as thatidentified by the full family group.

Social workers were also subdivided based on their experience in clin-ical social work practice and the critical care environment. This enabled thecreation of four subgroups identified as less then 5 years experience in ICUsocial work, over 5 years experience in ICU social work, less then 5 yearsexperience in clinical social work, and over 5 years experience in clinicalsocial work (Table 11). Social workers with less then 5 years experience inboth ICU and clinical social work together with social workers with over5 years experience in clinical social work ranked the factors in an orderidentical to the ranking of the family subgroups “spouse” and “parent.”

This may be interpreted as showing an excellent understanding of fam-ily needs in the intensive care environment from a social worker perspective.It also demonstrates social workers’ ability to spend time assessing familyneeds, especially during the hectic initial period post admission. The onlysubgroup to rank the factors differently were the social workers with over5 years experience in ICU social work.

Comparison With Previous Studies

Despite advances in medical technology and the increased inclusion of fam-ilies in ICU, the overall results of the current study support the results


previously established by Molter (1979), Daley (1984), Leske (1986), O’Neill-Norris and Grove (1986), Lynn-McHale and Bellinger (1988), Chartier andCoutu-Wakulczyk (1989), Coutu-Wakulczyk and Chartier (1990), Forresteret al. (1990), Koller (1991), Macey and Bouman (1991), Davis-Martin (1994),Lopez-Fagin (1994), Bijttebier et al. (2000), Delva et al. (2002), Hinkle et al.(2009), and Bailey, Sabbagh, Loiselle, Boileay, and McVey (2010). A closerlook at the breakdown of family needs into more important and less impor-tant categories illustrates a change over time, however, from an emphasis onthe need “to feel there is hope” to a need “to have questions answered hon-estly.” In a significant number of ICU cases it is very difficult for the family“to feel there is hope” when the treating team answer questions honestly.This change may be attributed to the change in family participation in theICU environment. When many of the previous studies were undertaken,there was a very strict visiting schedule in ICU for family members. Theywere often only allowed to visit for 10 minutes every 1 to 2 hours. Todaythere is an open visiting policy in most ICUs that results in the family beingmore aware of the expected outcomes of the patient. They are also ableto monitor more closely the care given to the patient, thus increasing theirunderstanding of the patient’s treatment and prognosis.

As with previous studies (Molter, 1979; Leske, 1986; O’Neill-Norris &Grove, 1986) the current results support the family’s need “to feel that thehospital personnel care about the patient” and “to know the expected out-comes” (prognosis). Identifying caring staff and being made aware of theprognosis of the patient are both needs that one would expect would remainconstant over time given the nature of the critical care environment. Thefamily members participating in the current study ranked “to have the wait-ing room near the patient” and “to be called at home about changes in thepatients condition” lower than those from the previous studies, reinforcingthe suggestion that these needs are more reflective of a time characterizedby lower levels of access to the patient by family.

As with the current study, family members in previous studies (Molter,1979; Leske, 1986; O’Neill-Norris & Grove, 1986) were not concerned fortheir own personal needs. While only one of the less important ranked needsis the same (“to be encouraged to express emotions”), family members in theprevious studies did not find it important to discuss their emotions/feelings,have someone help with financial problems, have another person visit theICU with them or to have a specific place to be alone while in hospi-tal. The only need that both the previous studies and the current studyagree on as being of lesser importance is the need “to be encouraged toexpress emotions.”

Implications for Social Work Practice

As previously discussed, Delva et al. (2002) highlighted the implications forsocial work practice in this field by identifying four types of intervention


where the focus of social workers should be aimed. They include assess-ment, provision of information, provision of emotional support, and assistingwith solving practical problems. Delva et al. (2002) argued, quite rightly,that social work input is part of the multidisciplinary approach and as sucha joint approach to meeting family needs allows a consistent method ofworking with families where all team members provide psychological sup-port. In the current study only 19% of social workers who participatedwere employed full time in ICU. Subsequently, a reduced amount of sup-port can be offered by social workers thus highlighting the need for awell-functioning multidisciplinary team.

In terms of assessment, while nurses and doctors undertake an initialmedical assessment, the social worker may be in a position to completea psychosocial assessment by gathering specific information relating to thefamily’s ability to cope with the prognosis, the ICU environment, their pre-vious experience in similar situations, their understanding of the eventsleading to the ICU admission, and any extended social support networksthey can access during this time.

While it is not the responsibility of the social worker to deliver medicalinformation, it is important that they have an understanding of the patient’scondition and prognosis so that they can assist the family in coping withwhat lay ahead of them (Delva et al., 2002). Social workers are in the uniqueposition of being able to liaise between doctors, nurses, and the family anddiscuss expectations with the family in terms that are understandable.

Providing emotional support is something that social workers are goodat. An individual or family in crisis compels a social worker into their role ofcounsellor in an attempt to assist the family or individual in dealing with thepresenting problem. It has been well established in previous literature thatthe admission of a relative to ICU can induce stress, fear, and an inabilityto cope with the news. The role of the social worker in this situation is tostrengthen coping behavior, support adaptive behavior, help family mem-bers to express their feelings, assist family members to adapt to the ICUenvironment, and prevent maladaptive behaviors before they get to crisispoint (Delva et al., 2002).

Finally, social workers are armed with valuable information that maylook trivial to other professions, but is very useful in providing solutionsto practical problems for family members. Assistance with accommodation,food or parking, for instance, will relieve the strain on both local andnon-local families. Information relating to hospital services, transportation,financial support, and childcare will assist those who are unfamiliar withservices they are entitled to access. The social worker plays an importantrole as a member of the ICU multidisciplinary team and as such they shouldaim to become involved early in the admission and encourage the sharing ofinformation among team members. This will provide family members withthe support they require at this difficult time.


CONCLUSION

This study was, to a large extent, a replication study, although where pre-vious studies have investigated family needs in intensive care from theperspective of the family and nurses, the current study investigated familyneeds in intensive care from the perspective of the family and clinical socialwork specialists. This research focused on patients unexpectedly admittedto ICU as opposed to previous research that did not discriminate betweenexpected and unexpected admissions. This provided a valuable opportu-nity to assess the impact of an unexpected admission in the critical 48-hourperiod following the patient’s admission.

There are, however, two essential limitations of this study. First, thenumber of participants in each group is lower in comparison than someof the other studies carried out (Molter, 1979; Leske, 1986; Lynn-McHale,1988; & Forrester, 1990), thus prompting caution when comparing results.The second limitation is that just over half of the total participants weresourced from a single hospital, thus limiting the generalizability of theresults. These are minor limitations however and after taking them intoconsideration, the case can be made that the results of this study doprovide support to the previous work of Molter (1979), Daley (1984),Leske (1986), O’Neill-Norris and Grove (1986), Lynn-McHale and Bellinger(1988), Macey and Bouman (1991), Chartier and Coutu-Wakulczyk (1989),Coutu-Wakulczyk and Chartier (1990), Forrester et al. (1990), Koller (1991),Davis-Martin (1994), Lopez-Fagin (1994), Bijttebier et al. (2000), Delva et al.(2002), Hinkle et al. (2009), and Bailey et al. (2010). In doing so, the resultsof this study also support the use of the CCFNI as a good diagnostic tool infamily needs assessment in the intensive care environment.

An analysis of the individual need statement results illustrated onlyminor changes in the pure ranking order from 1979 to 2003. The most sig-nificant distinction in the results saw a change in direction from the need “tofeel there is hope” to a need “to have questions answered honestly.” Thissignifies a change that is most likely related directly to improved communi-cation with families over the years and a subsequent increase in the role ofthe family in the intensive care environment. Education and experience havealso alerted families to the notion that there are times in our lives when asindividuals we do not have any control over what occurs. As such, familiesseem to acknowledge that there are “unmeetable needs” during the crisisperiod that follows the admission of a family member to ICU. In acknowl-edging this, the change in priority from feeling the need for hope to havingquestions answered honestly is justified.

The factor analysis conducted for this study showed that the impor-tance of the need for assurance and anxiety reduction in family membersare similar to those identified in previous studies. Overall, the family cat-egories were ranked in a different order to those of Molter (1979), Leske


(1986), O’Neill-Norris and Grove (1986), Lynn-McHale and Bellinger (1988),and Forrester et al. (1990). Social workers in this study ranked the cate-gories in the same order as the family with three of the four social worksubgroups also matching with the order established by the family. Thissupports the suggestion put forward by Delva et al. (2002) that socialworkers are in a position to be able to offer families more time to dis-cuss the issues that are of concern. It also indicates a unity in the thoughtprocesses of ICU social workers, which is a positive outcome for theprofession.

Finally, the results of this study support the need for multidisciplinarywork in the intensive care environment. Due to time restrictions and heavyworkloads in units outside of ICU, social workers do not always have theability to spend extended periods of time with families. The results of thisstudy indicate the importance of sharing information among the ICU multi-disciplinary team to ensure the provision of holistic care to both the patientand their family.

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Social Workers' Perspectives on the Psychosocial Needs of Families During Critical Illness

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