The perceived needs of Jordanian families of hospitalized, critically ill patients

Experiences on health-related quality of life of Jordanian patients living with heart failure: A qualitative study

BACKGROUND

Quantitative studies have provided valuable statistical insights into Health-Related Quality of Life (HRQoL) among patients with Heart Failure (HF), yet they often lack the depth to fully capture the nuanced, subjective experiences of living with HF particularly in the specific context of Jordan. This study explores the personal narratives of HF patients to understand the full impact of HF on their daily lives, revealing HRQoL aspects that quantitative metrics often miss. This is crucial in developing regions, where the increasing prevalence of HF intersects with local healthcare practices, cultural views, and patient expectations, providing key insights for tailored interventions and better patient care.

METHODS

Utilizing a phenomenological qualitative design, this study conducted face-to-face semi-structured interviews with 25 HF patients to deeply explore their lived experiences. Thematic analysis was employed to identify major themes related to their perceptions of HF as a disease, its impact on various HRQoL domains, and their recommended strategies to enhance HRQoL.

RESULTS

The study involved 25 participants (13 males, 12 females), aged 26-88 years (mean 63), with diverse education and heart failure (HF) severities. It revealed three themes: HF perceptions, its impact on health-related quality of life (HRQoL) across physical, psychosocial, spiritual, cognitive, and economic domains, and HRQoL improvement strategies. Participants had varied HF knowledge; some lacked basic understanding. The physical impact was most significant, affecting daily life and causing symptoms like breathing difficulties, coughing, edema, and fatigue. This physical aspect influenced their psychosocial and spiritual lives, cognitive functions, and economic stability, leading to fear, frustration, worry, social isolation, spiritual and cognitive challenges, and employment problems.

CONCLUSIONS

The results underscores the need for holistic healthcare approaches, integrating medical, psychological, and social support. Key recommendations include integrated care models, comprehensive patient education, support networks, and policy interventions to enhance HF patient care.

Open visitation policy in intensive care units in Jordan: cross-sectional study of nurses' perceptions

INTRODUCTION

Intensive care unit patients and families experience significant stress. It creates frustrations, nervousness, irritability, social isolation for patients, anxiety, and depression for families. An open visitation policy with no time or duration limits may assist in reducing these negative experiences. However, most Jordanian and regional hospitals within the Middle-East and Northern Africa (MENA) have not implemented this strategy.

PURPOSE

To evaluate nurse managers' and nurses' perspectives on the effects of an open visitation policy at intensive care units (ICUs) on patients, families, and nurses' care.

METHOD

A cross-sectional, descriptive, and comparative survey design was used.

RESULTS

A total of 234 nurses participated in the study; 59.4% were males, and 40.6% were females. The mean of their age was 28.6 years, with a mean of 4.1 years of experience. Nurses generally had negative perceptions and attitudes toward the open visitation policy and its consequences on the patient, family, and nursing care.

CONCLUSIONS

ICU managers and staff nurses did not favor implementing an open visitation in their units despite its known benefits, international recommendations, and relevance and compatibility with the local religious and cultural context. A serious discussion regarding this hesitation from the side of the healthcare professionals should be started to find a suitable solutions that consider the benefits of the open visitation policy and the challenges that prevent its implementation in the Jordanian and Arabic cultures.

Perception of nursing students from the Middle East about caring: A descriptive, comparative, cross-sectional study

AIM

To investigate the perception of undergraduate nursing students in different countries in the Middle East about caring.

DESIGN

A cross-sectional, descriptive, comparative design.

METHODS

A total of 1,582 nursing students from six different countries in the Middle East completed the Caring Dimensions Inventory.

RESULTS

The total mean score of caring was 138.8 (± 15.8), indicating a high level of caring. The highest mean score was for nursing students from Egypt (M = 145.37 ± 15.97), whereas the lowest was for nursing students from Palestine (M = 135.36 ± 13.48). The caring perception was more significant for female students than male students, and no significant correlation was found between students' ages and caring scores.

CONCLUSIONS

The high level of caring among nursing students reflects the involvement of caring behaviour in the nursing curricula, which motivates nursing schools to continue stressing the importance of caring and to enhance this behaviour among their graduates.

PATIENT OR PUBLIC CONTRIBUTION

Improving the students' caring competencies as recommended by the study will influence the caregiving quality in the future that will be reflected in nurse-patient caring relationships and raise the patients' and public satisfaction with nursing care.

Family attendance during critical illness episodes: Reflection on practices in Arabic and Muslim contexts

It is common practice in healthcare systems in the Arabic region to exclude relatives when patients receive treatment for critical emergent incidents or illnesses. This exclusion is despite family members' wishes for proximity and cultural and religious values that mean being with unwell people is considered a form of worship or religious act. The marked lack of implementation of relatives' wishes in this regard is coupled with a paucity of relevant policies, guidelines, and research, despite patient populations in these countries being traditional in nature, religious, and having strong connections within their families and extended social units. The present authors reflected on this concern and advocated for increased attention to the needs and rights of critically ill patients and their families to support better quality, holistic care, especially during critical illness incidents. Healthcare professionals should consider allowing families to be present with their patients in such circumstances and appreciate the importance of family presence, despite the acknowledged challenges. The recommendations presented in this reflection may support the implementation of effective, holistic healthcare services in these countries. This reflection is also relevant to any context where care for Arabic or Muslim patients is provided.

Psychometric Properties of the "ICU Nurses" Perceptions Questionnaire of Self-Performance with Families of Critically Ill Patients (Persian Version)

BACKGROUND AND PURPOSE

Nurses' self-perception of their performance toward family members of patients is one of the most important issues in predicting family adaptive behaviors. This study analyze the psychometric properties of the Persian version of ICU nurses' perceptions questionnaire of self-performance with families of critically ill patients.

METHODS

Among 135 intensive care nurses, to determine face validity, 10 nurses were asked to comment on, comprehensibility, grammar, and writing of items. Exploratory factor analysis was used to assess construct validity.

RESULTS

The intra-cluster correlation coefficient (ICC) was 0.82 and Cronbach's alpha was 0.74. Exploratory factor analysis showed the first nine related factors have 65.22% variance.

CONCLUSION

Persian version of "ICU nurses' perceptions of self-performance with families of critically ill patients" had good reliability and validity.

The intensive care unit visiting study: A multisite survey of visitors

BACKGROUND

Being able to visit a critically ill relative provides comfort to family members and has recognised benefits to the patient. Limited research has been conducted on demographic characteristics and visiting behaviours of family members with a relative in the intensive care unit (ICU).

OBJECTIVES

The objective was to provide an overview of local ICU visitor behaviours and practices across four metropolitan units in Australia.

METHODS

A convenience sample of 440 participants from four ICUs across a metropolitan city in eastern Australia was required for the study. A descriptive 22-item self-report survey was used. Data were collected from four ICUs in a metropolitan city in eastern Australia. Sample characteristics and other variables were analysed using descriptive statistics.

RESULTS

Data collection was undertaken from April 2018 to May 2019. Four hundred sixty-two (n = 462) ICU visitors responded. There were no significant differences between visitor characteristics across the four hospitals. The mean age of the respondents was 49 years, the youngest participant being 18 years and the oldest being 93 years, with most visitors being women (n = 312, 68%). The participants were more likely to be close relatives such as spouses (n = 117, 25%), parents (n = 113, 24%), or children (n = 79, 17%). Visitors reported different methods by which they received information about visiting policies across units and indicated that they would have visited more frequently if able. Although most respondents rated their ICU visiting experience favourably, some reported being frequently asked to leave the patient's bedside impacted their experience.

CONCLUSIONS

This study has highlighted that families want to remain in close proximity when they have a relative in the ICU. Despite visiting hours being flexible, most families visit midmorning so that they can talk with staff. Data captured in this study can be used toward improving the ICU visiting experience for family members.

The process of giving information to families in intensive care units: A narrative review

AIM

Information is one of the most important needs of families of critical patients. Healthcare professionals also identify the great value of communication with families to reduce their anxiety and stress. Despite this, families may feel inadequately informed, causing added suffering. The purpose of this study is to provide an understanding of both families' and healthcare professionals' perspectives on information giving within intensive care units (ICU).

METHOD

A narrative review was conducted using MEDLINE, CINAHL, PsycINFO databases and the Cochrane Library to identify studies published in either English or Spanish from 2002 to 2018.

RESULTS

47 studies were included, and five categories were identified: 1)"the need to know"; 2)family satisfaction with the information received; 3)impact of information on families' experiences in the ICU; 4)nurses and physicians' perceptions of information transmission, and 5)information process in the ICU.

CONCLUSIONS

Providing honest and truthful information to the families of critical patients is essential to reduce family anxiety and increase family control, although this often appears to be inadequately accomplished by staff. Interdisciplinary involvement in information giving may be beneficial for both families and ICU professionals. This review brings new understanding about the process of information to families of ICU patients and it can be used to improve the quality and humanization of care in the ICUs.

Needs and stressors of parents of term and near-term infants in the NICU: A systematic review with best practice guidelines

Having a sick infant in the NICU can be quite stressful and overwhelming to parents. They require support and may have varied needs. A systematic review of qualitative and quantitative studies from 5 electronic databases (Ovid Medline, EMBASE, PsycINFO, CINAHL and Sociological Abstracts), covering January 2001 - March 2016 identified the needs and stressors of parents of term or near-term Infants in the NICU. Six articles addressed the needs and 14 identified the stressors of parents. Parents' most important need was for accurate and honest information. Needs focused around sensitive infant care and involvement in decision-making. The greatest stressor for parents was alteration to the parental role, followed by infant appearance. Fathers and parents of infants undergoing surgery are an under-researched population. Based on the evidence, enhancing staff-parent communication would better meet parental needs and reduce stressors. Our key recommendations highlight the need for family-centred and individualised care practices in the NICU.

Needs of parents in a surgical neonatal intensive care unit

AIM

While there is evidence of parental needs in the neonatal intensive care unit (NICU), parents of newborns admitted for general surgery are an under-researched population. This study aimed to identify needs in parents of newborns admitted to the NICU for general surgery and whether health-care professionals meet these needs.

METHODS

This was a prospective cohort study of 111 parents (57% mothers) of newborns admitted to a surgical NICU for general surgery in Australia from January 2014 to September 2015. Parents completed the Neonatal Family Needs Inventory (NFNI), comprising 56 items in five subscales (Support, Comfort, Information, Proximity, Assurance) at admission and discharge, as well as the Social Desirability Scale (SDS). Data were analysed using parametric and non-parametric techniques.

RESULTS

At both admission and discharge, parents rated Assurance (M = 3.8, standard deviation (SD) = 0.24) needs as the most important, followed by Proximity (M = 3.6, SD = 0.32) and Information (M = 3.5, SD = 0.38). Mothers rated Assurance significantly more important than fathers (P < 0.02). Overall, parents' most important needs were having questions answered honestly (M = 3.96, SD = 0.19), seeing their infant frequently and knowing about the medical treatment (both M = 3.95, SD = 0.23). The 10 most important needs were met for more than 96% of parents, with no evidence of response bias.

CONCLUSIONS

Reassurance is a priority need for parents in the surgical NICU. Mothers' and fathers' needs may be best met by practices based on family-centred, individualised care principles.

Analysis of the difference between importance and satisfaction of the needs of family members of critical patients

OBJECTIVE

To analyze the difference between the degree of importance and satisfaction of the needs of family members of patients in an Intensive Care Unit (ICU).

DESIGN

A descriptive, cross-sectional analytical study was carried out.

SETTING

Medical - surgical ICU of a university hospital in Chile.

PARTICIPANTS

Family members of critical patients with a length of stay of ≥ 48hours, over 18 years of age, and with at least one visit to the patient.

VARIABLES OF INTEREST

The Critical Care Family Needs Inventory questionnaire was used to determine the difference between the degree of importance and satisfaction of the needs of the family members. In addition, the needs were classified according to the categories proposed by importance - performance analysis (IPA).

RESULTS

A total of 253 family members were recruited, observing a negative gap (satisfaction <importance) in 100% of communication needs and in 51.9% of support needs. In turn, 8.9% of the needs were priority needs according to the IPA, including assistance with financial problems, contact in case of changes in the patient condition, talk about the possibility of death, and the reception of guidance at the patient bedside.

CONCLUSIONS

A high level of importance, compared to low levels of satisfaction, determines a negative gap in most of the needs of the family of the critical patient, particularly those referred to communication. Despite this, a low proportion of the needs should be addressed on a priority basis.

Experiences and needs of families with a relative admitted to an adult intensive care unit: a qualitative systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of the proposed review is to determine the best available qualitative evidence to guide healthcare workers when providing care and support for families of relatives in an adult intensive care unit (ICU). The specific objective is to explore the experiences and needs of families with a relative in an adult ICU.

Needs of relatives of critically ill patients in an academic hospital in Chile

OBJECTIVE

To identify the importance of the needs of family members of patients in an intensive care unit (ICU).

METHOD

Descriptive, comparative and cross-sectional study based on a secondary data analysis of 251 relatives of ICU patients at a university hospital in Santiago, Chile. Using non-random sampling, the 'Critical Care Family Needs Inventory' was used to establish the family needs, as well as a sociodemographic questionnaire that included: age, gender, educational level, patient relationship and previous ICU experience. A descriptive statistical analysis, Student's T test and ANOVA were performed.

RESULTS

The most important family needs related to the dimensions of 'security' (mean=3.90) and 'information' (mean=3.76), while those of minor importance with 'support' (mean=3.09). In the latter, differences were observed at an older age (P<.05), an educational level (P<.001) and relationship with the patient (P<.05).

CONCLUSIONS

The most relevant needs for family members in the ICU are related to safety and information. Less important needs are influenced by certain sociodemographic variables. Identifying the degree of importance of family needs will allow the health team to improve its relationship with families in ICUs.

Palestinian community perceptions of do-not-resuscitation order for terminally Ill patients: A qualitative study

AIM AND OBJECTIVES

To illustrate the Palestinian community's views, opinions and stances about the concept of do-not-resuscitate for terminally ill patients.

BACKGROUND

Do-not-resuscitate orders are practised in many countries worldwide, but there is no consensus on their practice in the Middle East. Do-not-resuscitate orders may be applied for terminally ill paediatric patients. Some studies have been conducted describing people's experiences with these do-not-resuscitate orders. However, few studies have considered community perspectives on do-not-resuscitate orders for terminally ill patients in Palestine.

DESIGN

A descriptive-qualitative design was adopted.

METHODS

A purposive sample of 24 participants was interviewed, with consideration of demographical characteristics such as age, gender, education and place of residency. The participants were recruited over a period of 6 months. Individual semistructured interviews were utilised. These interviews were transcribed and analysed using thematic analysis.

FINDINGS

Significantly, the majority of the participants did not know the meaning of do-not-resuscitate and thought that removal of life-sustaining devices and do-not-resuscitate were the same concept. Most of the interviewees adopted stances against do-not-resuscitate orders. Several factors were suggested to influence the decision of accepting or rejecting the do-not-resuscitate order. The majority of the participants mentioned religion as a major factor in forming their viewpoints. The participants expressed different views regarding issuing a law regarding do-not-resuscitate orders.

CONCLUSION

Our findings provide a unique understanding that there is a general misunderstanding among our participants regarding the do-not-resuscitate order. Further research with policymakers and stakeholders is still required.

The needs of the relatives in the adult intensive care unit: Cultural adaptation and psychometric properties of the Chilean-Spanish version of the Critical Care Family Needs Inventory

INTRODUCTION

The admission of a patient to an intensive care unit is an extraordinary event for their family. Although the Critical Care Family Needs Inventory is the most commonly used questionnaire for understanding the needs of relatives of critically ill patients, no Spanish-language version is available. The aim of this study was to culturally adapt and validate theCritical Care Family Needs Inventory in a sample of Chilean relatives of intensive care patients.

METHODS

The back-translated version of the inventory was culturally adapted following input from 12 intensive care and family experts. Then, it was evaluated by 10 relatives of recently transferred ICU patients and pre-tested in 10 relatives of patients that were in the intensive care unit. Psychometric properties were assessed through exploratory factor analysis and Cronbach's α in a sample of 251 relatives of critically ill patients.

RESULTS

The Chilean-Spanish version of the Critical Care Family Needs Inventoryhad minimal semantic modifications and no items were deleted. A two factor solution explained the 31% of the total instrument variance. Reliability of the scale was good (α=0.93), as were both factors (α=0.87; α=0.93).

CONCLUSION

The Chilean-Spanish version of theCritical Care Family Needs Inventory was found valid and reliable for understanding the needs of relatives of patients in acute care settings.

Relationship between motivational style and glycemic control in Jordanian patients with type 2 diabetes mellitus

BACKGROUND

Although, there is increased recognition of the importance of blood glucose control and diabetes education in type 2 diabetes mellitus (T2DM), the relationship between motivation and long term outcomes, glycemic control, are lacking. The primary aims of the present study were to: (i) describe the motivational style of Jordanian patients with T2DM regarding self-care management, taking medications, and self-monitoring of blood glucose (SMBG), as well as following therapeutic dietary instructions and exercising regularly; and b) examine the significance of these factors in predicting glycemic control.

METHODS

A package including a treatment self-regulation questionnaire concerning diabetes, was administered to a convenience sample of 110 patients with T2DM. In addition, the most recent HbA1c results were extracted from the patients' medical records.

RESULTS

Fifty-eight patients (52.7 %) reported being intrinsically motivated with regard to taking medication and regular SMBG, whereas half the participants (50 %) were intrinsically motivated to follow therapeutic dietary instructions and regular exercise. Patients who were intrinsically motivated were 8.3-fold more likely (95 % confidence interval [CI] 1.44-47.86) to have glycemic control than those reporting extrinsic motivation. In addition, those who were intrinsically motivated to follow therapeutic dietary instructions and exercise regularly were 10.50-fold more likely (95 % CI 2.50-48.78) times more likely to report glycemic control than those reporting extrinsic motivation.

CONCLUSION

Interventional strategies should focus on promoting intrinsic motivation in order to enhance glycemic control.

Patient and family involvement in adult critical and intensive care settings: a scoping review

BACKGROUND

Despite international bodies calling for increased patient and family involvement, these concepts remain poorly defined within literature on critical and intensive care settings.

OBJECTIVE

This scoping review investigates the extent and range of literature on patient and family involvement in critical and intensive care settings. Methodological and empirical gaps are identified, and a future agenda for research into optimizing patient and family involvement is outlined.

METHODS

Searches of MEDLINE, CINAHL, Social Work Abstracts and PsycINFO were conducted. English-language articles published between 2003 and 2014 were retrieved. Articles were included if the studies were undertaken in an intensive care or critical care setting, addressed the topic of patient and family involvement, included a sample of adult critical care patients, their families and/or critical care providers. Two reviewers extracted and charted data and analysed findings using qualitative content analysis.

FINDINGS

A total of 892 articles were screened, 124 were eligible for analysis, including 61 quantitative, 61 qualitative and 2 mixed-methods studies. There was a significant gap in research on patient involvement in the intensive care unit. The analysis identified five different components of family and patient involvement: (i) presence, (ii) having needs met/being supported, (iii) communication, (iv) decision making and (v) contributing to care.

CONCLUSION

Three research gaps were identified that require addressing: (i) the scope, extent and nature of patient involvement in intensive care settings; (ii) the broader socio-cultural processes that shape patient and family involvement; and (iii) the bidirectional implications between patient/family involvement and interprofessional teamwork.

Questionnaires on Family Satisfaction in the Adult ICU: A Systematic Review Including Psychometric Properties

OBJECTIVES

To perform a systematic review of the literature to determine which questionnaires are currently available to measure family satisfaction with care on the ICU and to provide an overview of their quality by evaluating their psychometric properties.

DATA SOURCES

We searched PubMed, Embase, The Cochrane Library, Web of Science, PsycINFO, and CINAHL from inception to October 30, 2013.

STUDY SELECTION

Experimental and observational research articles reporting on questionnaires on family satisfaction and/or needs in the ICU were included. Two reviewers determined eligibility.

DATA EXTRACTION

Design, application mode, language, and the number of studies of the tools were registered. With this information, the tools were globally categorized according to validity and reliability: level I (well-established quality), II (approaching well-established quality), III (promising quality), or IV (unconfirmed quality). The quality of the highest level (I) tools was assessed by further examination of the psychometric properties and sample size of the studies.

DATA SYNTHESIS

The search detected 3,655 references, from which 135 articles were included. We found 27 different tools that assessed overall or circumscribed aspects of family satisfaction with ICU care. Only four questionnaires were categorized as level I: the Critical Care Family Needs Inventory, the Society of Critical Care Medicine Family Needs Assessment, the Critical Care Family Satisfaction Survey, and the Family Satisfaction in the Intensive Care Unit. Studies on these questionnaires were of good sample size (n ≥ 100) and showed adequate data on face/content validity and internal consistency. Studies on the Critical Care Family Needs Inventory, the Family Satisfaction in the Intensive Care Unit also contained sufficient data on inter-rater/test-retest reliability, responsiveness, and feasibility. In general, data on measures of central tendency and sensitivity to change were scarce.

CONCLUSIONS

Of all the questionnaires found, the Critical Care Family Needs Inventory and the Family Satisfaction in the Intensive Care Unit were the most reliable and valid in relation to their psychometric properties. However, a universal "best questionnaire" is indefinable because it depends on the specific goal, context, and population used in the inquiry.

Patient and family/friend satisfaction in a sample of Jordanian Critical Care Units

AIM

The aim of the study was to assess the validity of family members/friends as proxies by comparing perceptions of satisfaction with care and decision making between critically ill patients and their family/friends.

DESIGN

A comparative, descriptive cross-sectional study.

SETTING

Seven Critical Care Units across four public and military hospitals in the centre and southern regions of Jordan.

METHODS

A modified version of the Family Satisfaction-ICU (FS-ICU) questionnaire was distributed to Critical Care Unit (CCU) patients before hospital discharge. In addition, up to two family members/close friends were also asked to complete the questionnaire.

RESULTS

A total of 213 patients (response rate 72%) and 246 family members/friends (response rate 79%) completed and returned the questionnaire. Although the majority of family members/friends and patients were satisfied with overall care, patients were generally significantly less satisfied (mean (SD) care subscale 75.6 (17.8) and 70.9 (17.3), respectively, (p=0.005). When individual items were examined, significant differences in nursing care (family/friends 80.1 (20.7) versus patient 75.9 (22.2), p=0.038) and inclusion in decision making (family/friends 53.9 (33.2) versus patient 62.0 (34.2), p=0.010) were found.

CONCLUSION

The study showed a degree of congruence between patients and their family members/friends in relation to their satisfaction with the CCU experience. Thus, views of family/friends may serve as a proxy in assessing care and decision making processes of critically ill patients.

RELEVANCE TO CLINICAL PRACTICE

Appropriate training of the critical care team and provision of strategies to address the concerns of patients' families are needed to improve overall patient satisfaction.

The satisfaction of families in the care of their loved ones in CCUs in Lebanon

BACKGROUND

The needs of family members vary among cultures and hospitals. Often, these needs remain unmet increasing their stress and anxiety and decreasing their satisfaction with care, which may negatively impact the quality of patient care.

AIMS

To assess the satisfaction of families with the care of their loved ones in critical care units (CCUs) in a large university medical centre in Lebanon and to assess the predictors of satisfaction.

METHODS

A cross-sectional descriptive design was conducted using the Critical Care Family Satisfaction Survey (CCFSS). The participants were 123 adult relatives or significant others of patients cared for in both adult and paediatric intensive care units for at least 3 days.

RESULTS

The CCFSS showed acceptable internal reliability and construct validity in a Lebanese population. In general, families were satisfied with the care their loved ones received in the CCUs, and the least satisfaction was in the area of 'comfort' and the highest was in 'assurance'. Younger family members with more education were less satisfied with care and Christian families expressed less satisfaction with informational needs compared with Muslim families. Families of children in the paediatric CCU expressed least satisfaction with care. Gender, residency, relationship to patient, unit, prior experience in a CCU and diagnosis had no effect on satisfaction scores.

CONCLUSIONS

Assessment of family satisfaction in different cultures is important as each culture has specific needs that are essential to decipher.

IMPLICATIONS FOR PRACTICE

Patient satisfaction leads to improved quality of care; thus, it behoves nurses to meet the needs of families from different cultures to help them cope and increase their satisfaction, which leads to improve patient outcomes.

Information and support needs of adult family members of patients in intensive care units: an Iranian perspective

Nurses are required to be knowledgeable about the needs of family members of patients hospitalised in the intensive care unit. The identification of the importance and priority of family members’ needs enables nurses to provide appropriate information and support for family members. The aim of this study was to describe the needs of family members of patients hospitalised in the intensive care unit. A descriptive cross-sectional study using survey methods was conducted. Family members of patients hospitalised for 24–72 hours in the intensive care units of 27 public and teaching hospitals in an urban area of Iran were chosen using the random sampling method. The 45-item Persian version of the Critical Care Family Needs Inventory was used to collect numerical data. Four hundred and fifty family members participated. The mean score for each of the 45 items ranged from 2.45 to 3.72. Ten items were rated by responders as very important, with 93.13% of the sample rating ‘Giving an honest answer to questions’ as having the highest level of importance. ‘To have the pastor visit’ was reported to be the least important need. Age, family relations, marital status and level of education related to the importance level of some of the perceived needs. It is concluded that the most important needs consist of five items relating to the ‘assurance dimension’, while the least important ones are related to the ‘support dimension’. The incorporation of the needs of family members into the nursing education programme is suggested. The findings will help with the preparation of nurses, as future healthcare policy makers, to plan for meeting these needs and will reduce the psychological burden on family members of patients hospitalised in the intensive care unit.

The perceptions of the ward atmosphere in four Jordanian psychiatric hospitals from the perspective of patients' relatives

PURPOSE

To describes the perceptions of the ward atmosphere of psychiatric hospitals from the perspective of the relatives of people who were inpatients in those hospitals.

DESIGN AND METHODS

A nonexperimental descriptive survey was used. Data were collected using the Arabic version of Moos Ward Atmosphere Scale Ideal and Real forms.

FINDINGS

Data indicate that even though relatives of Jordanian mental health patients were generally positive about the ward atmosphere, they would like to see changes.

PRACTICE IMPLICATIONS

By describing their current and ideal treatment environments, participants have provided information that can guide interventions to change the ward atmosphere and thus help foster better patient treatment outcomes.

Informational support to family members of intensive care unit patients: the perspectives of families and nurses

Introduction:

The receiving information about the patients hospitalized in the intensive care unit is classified among the most important needs of the family members of such patients. Meeting the informational needs of families is a major goal for intensive care workers. Delivering honest, intelligible and effective information raises specific challenges in the stressful setting of the intensive care unit (ICU). The aim of this qualitative study was to explain perspectives of families of Intensive Care Unit patients and nurses about informational support.

Method:

Using a conventional content analysis approach, semi-structured interviews were conducted with participants to explore their perspectives of providing informational support to families of ICU patients. A purposeful sampling method was used to recruit nineteen family members of thirteen patients hospitalized in the ICU and twelve nurses from three teaching hospitals. In general, 31 persons participated in this study. Data collection continued to achieve data saturation.

Findings:

A conventional content analysis of the data produced three categories and seven sub-categories. The three main categories were as followed, a) providing information, b) handling information and c) using information. Providing information had three sub-categories consisting of “receiving admission news”, “receiving truthful and complete information” and receiving general information. Handling information had two sub-categories consisting ‘keeping information” and “gradual revelation”. Lastly, using information has two sub-categories consisting of “support of patient” and “support of family members”.

Conclusion:

The results of this study revealed perspectives of families of Intensive Care Unit patients and nurses about informational support. It also determines the nurses’ need to know more about the influence of their supportive role on family’s ICU patients informing. In addition, the results of present study can be used as a basis for further studies and for offering guidelines about informational support to the families of the patients hospitalized in the ICU.

A vulnerable population: families of patients in adult critical care

Families of patients in adult critical care are susceptible to physiological symptoms, emotional distress, persuasion, burden, and postintensive care syndrome-family, as defined by the Society of Critical Care Medicine. The specific aims of this article are to (1) describe the state of science about the concept of vulnerability of families of patients in adult critical care, through analysis and synthesis of relevant literature; (2) explore resources available to reduce or prevent vulnerability of this population; and (3) propose considerations for research with this population. Concept analysis and synthesis strategies support the definition of this concept through review of the literature to describe antecedents, defining characteristics, and consequences of the vulnerability of families of patients in adult critical care. The authors present resources for both families and health care professionals and recommendations for potential collaborative efforts that could reduce risks and promote the health of this vulnerable population.

Families' stressors and needs at time of cardio-pulmonary resuscitation: a Jordanian perspective

Background:

During cardio-pulmonary resuscitation, family members, in some hospitals, are usually pushed to stay out of the resuscitation room. However, growing literature implies that family presence during resuscitation could be beneficial. Previous literature shows controversial belief whether or not a family member should be present during resuscitation of their relative. Some worldwide association such as the American Heart Association supports family-witnessed resuscitation and urge hospitals to develop policies to ease this process. The opinions on family-witnessed resuscitation vary widely among various cultures, and some hospitals are not applying such polices yet. This study explores family members’ needs during resuscitation in adult critical care settings.

Methods:

This is a part of larger study. The study was conducted in six hospitals in two major Jordanian cities. A purposive sample of seven family members, who had experience of having a resuscitated relative, was recruited over a period of six months. Semi-structured interview was utilised as the main data collection method in the study.

Findings:

The study findings revealed three main categories: families’ need for reassurance; families’ need for proximity; and families’ need for support. The need for information about patient’s condition was the most important need. Updating family members about patient’s condition would reduce their tension and improve their acceptance for the end result of resuscitation. All interviewed family members wanted the option to stay beside their loved one at end stage of their life. Distinctively, most of family members want this option for some religious and cultural reasons such as praying and supplicating to support their loved one.

Conclusions:

This study emphasizes the importance of considering the cultural and religious dimensions in any family-witnessed resuscitation programs. The study recommends that family members of resuscitated patients should be treated properly by professional communication and involving them in the treatment process. The implications concentrate on producing specific guidelines for allowing family-witnessed resuscitation in the Jordanian context. Finally, attaining these needs will in turn decrease stress of those witnessing resuscitation of their relative.

The meaning and importance of vigilant attendance for the relatives of intensive care unit patients

AIM

To explore the meaning of vigilant attendance for relatives of critically ill patients in Greece.

BACKGROUND

A plethora of international research has identified proximity to the patient to be a major concern for relatives of critically ill patients. Greece however follows a strict visiting policy in intensive care units (ICUs) so Greek relatives spend great amounts of time just outside the ICUs.

DESIGN

This qualitative study adopted the social constructionist version of grounded theory.

METHOD

Data were collected from three ICUs in Athens through in depth interviews with 25 informants and approximately 10 h of observations outside the ICUs on 159 relatives.

FINDINGS

Vigilant attendance was one of the main coping mechanisms identified for relatives. Four subcategories were found to comprise vigilant attendance: (1) being as close as possible to feel relief, (2) being there to find out what is going on, (3) monitoring changes in the loved one and making own diagnosis and (4) interacting with the ICU professionals.

CONCLUSION

Vigilant attendance describes the way in which relatives in Greece stayed outside the ICUs. Relatives felt satisfaction from being close as the best alternative for not actually being inside the ICU and they tried to learn what was going on by alternative methods. By seeing the patients, relatives were also able to make their own diagnoses and could therefore avoid relying solely on information given to them. However, a prerequisite for successful vigilant attendance was to get on well with doctors and nurses.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Changes in visiting policies in Greece are needed to meet the needs of relatives adequately. Recommendations for changes with minimal investment of time and funding are made.

Needs and experiences of intensive care patients' families: a Saudi qualitative study

AIM

To identify the perceived needs of Saudi families of patients in Intensive Care in relation to their culture and religion.

BACKGROUND

Admission of a family member to an intensive care unit (ICU) is a deeply distressing and often unexpected life event to the family. Families of critically ill patients have needs that should be acknowledged and met by the ICU team. Literature is virtually silent on the issue of recognizing the ICU family needs in relation to the influence of their cultural values and religious beliefs.

DESIGN

A descriptive exploratory qualitative study.

METHOD

Individual, semi-structured interviews of a purposive sample of 12 family members were carried out between November 2011 and February 2012. The closest family members were recruited to participate in the interviews with a mean age of 44·25 years in eight mixed medical-surgical ICUs of eight major trauma hospitals in Saudi Arabia.

RESULTS

The family needs and experiences are described via six major themes: looking for information, maintaining reassurance, spiritual healing, maintaining close proximity, involvement in care and support not being facilitated. The results indicated that family members sought to access information readily to diminish their anxiety. They also needed to be reassured that the best care was being delivered to their loved one and to feel supported during this critical time. Saudi families have cultural and spiritual healing beliefs and practices including faith in God and that God is the ultimate healer, reading of the Qur'an, prayer and charity. These lessen their stress and connect them to hold on to hope. In addition, maintaining proximity to their ill family member was considered of the greatest importance to the families.

CONCLUSION

The study provided an in-depth understanding of the family members' experience of having a relative in Intensive Care and focussed on a range of unmet needs, particularly those related to culture and religion. The ICU team need to work collaboratively with family members to improve their experience.

RELEVANCE TO PRACTICE

The recognition of family needs, experiences and situations can enhance the care provided by the critical care team to patients and families.

Families' needs of critical care Muslim patients in Saudi Arabia: a quantitative study

AIM

To identify the needs of families of adult intensive care unit (ICU) patients in Saudi Arabia as perceived by family members and health care providers.

BACKGROUND

Family members of critically ill patients are likely to have specific needs that should be addressed by the critical care team and which, if unmet, may produce stress for patients' families and health care providers. The literature has yet to identify the needs of Muslim families in relation to religious beliefs and cultural values in critical care settings in Saudi Arabia.

DESIGN

A cross-sectional survey design.

METHOD

A total of 176 family members and 497 intensive health care providers were recruited from eight adult mixed medical-surgical ICUs between November 2011 and February 2012 utilizing a four-point Likert type scale self-administered questionnaire.

RESULTS

The findings revealed that family members and health care providers ranked assurance, information and cultural and spiritual needs as the most important, and support and proximity as least important. There were significant differences in the mean values found between family members and health care providers. A significant finding not identified in other studies was 'The need to have the health care providers handle the body of the dead Muslim with extreme caution and respect' which, under the dimension of cultural and spiritual needs, was perceived by family members to be the most important and by the health care providers as the fifth most important need.

CONCLUSION

The recognition of family needs in the critical care unit informed the development of interventions to meet family needs and improve the care quality.

Nurses empathy and family needs in the intensive care units

INTRODUCTION

The patients' families in intensive care units (ICUs) experience excessive stress which may disrupt their performance in daily life. Empathy is basic to the nursing role and has been found to be associated with improved patient outcomes and greater satisfaction with care in patient and his/her family. However, few studies have investigated the nursing empathy with ICU patients. This study aimed to assess nursing empathy and its relationship with the needs, from the perspective of families of patients in ICU.

METHODS

In this cross-sectional study, 418 subjects were selected among families of patients admitted to ICUs in Tabriz, Iran, by convenience sampling, from May to August 2012. Data were collected through Barrett-Lennard Relationship inventory (BLRI) empathy scale and Critical Care Family Needs Intervention (CCFNI) inventories and were analyzed using descriptive and inferential statistical tests.

RESULTS

Findings showed that most of the nurses had high level of empathy to the patients (38.8%). There was also statistically significant relationship between nurses' empathy and needs of patients' families (p < 0.001).

CONCLUSION

In this study we found that by increasing the nurse's empathy skills, we would be able to improve providing family needs. Through empathic communication, nurses can encourage family members to participate in planning for the care of their patients. However, further studies are necessary to confirm the results.

A Vulnerable Population

Families of patients in adult critical care are susceptible to physiological symptoms, emotional distress, persuasion, burden, and postintensive care syndrome—family, as defined by the Society of Critical Care Medicine. The specific aims of this article are to (1) describe the state of science about the concept of vulnerability of families of patients in adult critical care, through analysis and synthesis of relevant literature; (2) explore resources available to reduce or prevent vulnerability of this population; and (3) propose considerations for research with this population. Concept analysis and synthesis strategies support the definition of this concept through review of the literature to describe antecedents, defining characteristics, and consequences of the vulnerability of families of patients in adult critical care. The authors present resources for both families and health care professionals and recommendations for potential collaborative efforts that could reduce risks and promote the health of this vulnerable population.

Family needs and involvement in the intensive care unit: a literature review

AIMS AND OBJECTIVES

To understand the needs of critically ill patient families', seeking to meet those needs and explore the process and patterns of involving family members during routine care and resuscitation and other invasive procedures.

METHODS

A structured literature review using Cumulative Index to Nursing and Allied Health Literature, Pubmed, Proquest, Google scholar, Meditext database and a hand search of critical care journals via identified search terms for relevant articles published between 2000 and 2010.

RESULTS

Thirty studies were included in the review either undertaken in the Intensive Care Unit or conducted with critical care staff using different methods of inquiry. The studies were related to family needs; family involvement in routine care; and family involvement during resuscitation and other invasive procedures. The studies revealed that family members ranked both the need for assurance and the need for information as the most important. They also perceived their important needs as being unmet, and identified the nurses as the best staff to meet these needs, followed by the doctors. The studies demonstrate that both family members and healthcare providers have positive attitudes towards family involvement in routine care. However, family members and healthcare providers had significantly different views of family involvement during resuscitation and other invasive procedures.

CONCLUSION

Meeting Intensive Care Unit family needs can be achieved by supporting and involving families in the care of the critically ill family member. More emphasis should be placed on identifying the family needs in relation to the influence of cultural values and religion held by the family members and the organisational climate and culture of the working area in the Intensive Care Unit.

Jordanian parental needs of critically ill infants in neonatal intensive care units

This descriptive correlational study was conducted to identify perceived parental needs of critically ill infants in Neonatal Intensive Care Units (NICUs). Jordanian parents who were visiting their infants admitted in NICU ( N = 170) composed the study sample. Participants completed the demographic data sheet and the NICU Family Needs Inventory. Findings showed that parents ranked assurance, information and proximity as the most important needs, while comfort and support were ranked the lowest. The primary concern of parents was to be assured and informed about the progress of their infant. In addition, the results indicated that the mother’s perceived needs for support, information and proximity were significantly more important than the father's. Accordingly, nurses should establish a rapport with family members and provide them with understandable and honest information. Furthermore, the provision of quality, holistic, family-centered nursing care that relies primarily on early and comprehensive needs assessment, which correlates with infants’ outcomes, is imperative.

Jordanian nurses’ perceptions of their roles toward the families of hospitalised critically ill patients

The primary purpose of this study was to identify Jordanian nurses’ perceptions of their roles toward the families of hospitalised critically ill patients. Second, to examine the relationship between nurses’ role expectations and perceived role performance toward the families of hospitalised critically ill patients. A descriptive, correlational design was used. A convenience sample of 127 intensive care unit (ICU) nurses was recruited from ICUs located in four different hospitals in Jordan. Data were collected using a demographic data form, a Role Performance Subscale with 19 items and a Role Expectation Subscale with 14 items. Results indicated that Jordanian ICU nurses expected and performed interventions that required more time, emotion and communication skills less than interventions that required less time, emotion and communication skills.

Nurses' burnout and unmet nursing care needs of patients' relatives in a Turkish State Hospital

One of the biggest problems of work life today is burnout. With burnout, satisfaction of clients and service givers reduces. In this study, burnout levels of nurses working in the internal, surgical and intensive care units of a university hospital and the unmet needs of the patients' relatives related to nursing care were investigated. In the study, 225 nurses and 222 relatives of patients constituted the sample group of this study. Three separate forms were used in the study, namely, Nurse and Patient Relative Identification Form, the Maslach Burnout Inventory and the Nursing Services Satisfaction Inventory. In the study, burnout levels of the nurses were found to be high. Conditions like younger ages, scarcity of experience in the profession, lower levels of education, having chosen the profession and the unit they work in not willingly and working in environments like intensive care increase the burnout and as a result, expectations of the relatives of patients from nursing care are not fully met. Some suggestions have been made to make some regulations to prevent the burnout of nurses and to increase the satisfaction of relatives.

The experience of being an 'extracorporeal membrane oxygenation' relative within the CESAR trial

AIMS AND OBJECTIVES

This article reports a study exploring experiences of the relatives of adult patients receiving extracorporeal membrane oxygenation (ECMO) within the CESAR trial.

BACKGROUND

Relatives of ECMO patients have undergone unique experiences which have not previously been addressed in the literature and thus may have different needs which may not be met by present practice.

DESIGN AND METHODS

A grounded theory approach was adopted. In-depth unstructured interviews were conducted with family members of 10 surviving adult patients who had been randomized and received ECMO within the CESAR trial.

RESULTS

Relatives have a range of needs specific to the ECMO experience, these include the depth and positivity of information. Particular areas for support were concerning a perceived self-inflicted nature of illness, personal guilt, distance from home, receiving 'the call', weaning from sedation and transfer/discharge from the ECMO unit.

CONCLUSIONS

Relatives would benefit from the opportunity to talk about their 'ECMO experiences' following the patient's recovery to enable them and their families to 'move on'.

RELEVANCE TO CLINICAL PRACTICE

Interventions need to be in place to follow-up relatives and patients to provide ongoing support to the family unit.

Facilitated sensemaking: a feasibility study for the provision of a family support program in the intensive care unit

Family members of intensive care unit patients may develop anxiety, depression, and/or posttraumatic stress syndrome. Approaches to prevention are not well defined. Before testing preventive measures, it is important to evaluate which interventions the family will accept, use, and value. The purpose of this study was to evaluate the feasibility of an intervention for support for families of mechanically ventilated adults, grounded in a new midrange nursing theory titled "Facilitated Sensemaking." Families were provided a kit of supplies and the primary investigator coached families on how to obtain information, interpret surroundings, and participate in care. Participants were asked to complete an adapted Critical Care Family Needs Inventory and Family Support Program evaluation. Family members of 30 patients consented to participate; 22 participants completed the surveys. Internal consistency reliability of the adapted Critical Care Family Needs Inventory was high (alpha = .96). Results validated the importance of informational needs and provided a score indicating the family member's perception of how well each need was met, weighted by importance, which identified performance improvement opportunities for use by clinical managers. The program evaluation confirmed that families will use this format of support and find it helpful. Personal care supplies (eg, lotion, lip balm) were universally well received. Forty-two referrals to ancillary service were made. Operational issues to improve services were identified. As proposed in the Facilitated Sensemaking model, family members welcomed interventions targeted to help make sense of the new situation and make sense of their new role as caregiver. Planned supportive interventions were perceived as helpful.

Professional and cultural conflicts for intensive care nurses

AIM

This paper is a report of a study exploring intensive care nurses' experiences of conflicts related to practical situations when they encounter culturally diverse families of critically ill patients.

BACKGROUND

Conflicts can arise in critical care settings as a result of differing cultural and professional values. Nurses and families with diverse cultural backgrounds bring beliefs and understandings to the care situation that can have an impact on the care process. Such families are challenged in their efforts to maintain traditions, while some nurses are not sufficiently culturally aware. A limited number of studies have focused on such conflicts.

METHOD

Sixteen critical care nurses took part in multistage focus group interviews conducted from October 2005 to June 2006. The data were analysed using qualitative content analysis.

FINDINGS

The main theme, 'conflict between professional nursing practice and family cultural traditions', was based on three pairs of conflicting themes: 'culturally based need to participate actively in the care vs. nurses' professional perceptions of themselves as total care providers'; 'nurses' professional obligation to provide comprehensible information vs. culturally based communication difficulties and responses to illness'; and 'families' needs for cultural norms and self-determination vs. nurses' professional responsibility for the clinical environment'. In addition, each pair of themes contained several sub-themes.

CONCLUSION

Nurses need to negotiate with culturally diverse family members to address conflicts. In their encounters with such families, they should establish a balance between ethnocentricity and cultural sensitivity. An implication for practice is to increase nurses' competence in assessment of diversity.

Ethical values in caring encounters on a geriatric ward from the next of kin's perspective: an interview study

The aim of this study was to identify and describe the governing ethical values that next of kin experience in interaction with nurses who care for elderly patients at a geriatric clinic. Interviews with 14 next of kin were conducted and data were analysed by constant comparative analysis. Four categories were identified: receiving, showing respect, facilitating participation and showing professionalism. These categories formed the basis of the core category: 'Being amenable', a concept identified in the next of kin's description of the ethical values that they and the elderly patients perceive in the caring encounter. Being amenable means that the nurses are guided by ethical values; taking into account the elderly patient and the next of kin. Nurses' focusing on elderly patients' well-being as a final criterion affects the next of kin and their experience of this fundamental condition for high-quality care seems to be fulfilled.

Perceived and unmet needs of adult Jordanian family members of patients in ICUs

PURPOSE

To identify the self-perceived needs of adult Jordanians who have family members in ICUs and to explore whether those needs were being met.

DESIGN

A descriptive, exploratory design was used. A convenience sample of 139 family members of 85 critically ill patients was recruited from ICUs located in three different types of hospitals in Irbid, a city in northern Jordan. The three types of hospitals included Ministry of Health, university health system, and private sector.

METHODS

Family members who participated in this study were instructed to answer all the questionnaires that included: a demographic data form, the Critical Care Family Needs Inventory (CCFNI), and Needs Met Inventory (NMI).

RESULTS

The findings showed that the 10 most important needs identified by adult Jordanian family members were in the Assurance and Information subscales. The need "to be assured that the best care possible is being given to the patient" was reported as the most important need. Use of the NMI indicated that none of the 10 most important needs were perceived as being met.

CONCLUSIONS

Jordanian ICU nurses should be prepared to care for families in crisis, and the focus of nursing practice should be moved from just patient-centered care to a more holistic approach including family needs.

CLINICAL RELEVANCE

Meeting family needs should be emphasized in nursing practice. Meeting these needs might help family members to cope better and be more supportive to their critically ill loved one.

Short- and long-term impact of critical illness on relatives: literature review

AIM

This paper is a report of a literature review undertaken to identify the short- and long-term impact of critical illness on relatives.

BACKGROUND

Patients in intensive care can experience physical and psychological consequences, and their relatives may also experience such effects. Although it is recognized that relatives have specific needs, it is not clear whether these needs are always met and whether further support is required, particularly after intensive care.

DATA SOURCES

The following databases were searched for the period 1950-2007: Medline, British Nursing Index and Archive, EMBASE, CINAHL, PsycINFO and EMB Reviews--Cochrane Central Register of Clinical Trials.

SEARCH METHODS

Search terms focused on adult relatives of critically ill adult patients during and after intensive care. Recurrent topics were categorized to structure the review, i.e. 'relatives needs', 'meeting relatives' needs', 'interventions', 'satisfaction', 'psychological outcomes' and 'coping'.

RESULTS

Studies have mainly identified relatives' immediate needs using the Critical Care Family Needs Inventory. There are few studies of interventions to meet relatives' needs and the short- and long-term effects of critical illness on relatives.

CONCLUSION

Despite widespread use of the Critical Care Family Needs Inventory, factors such as local or cultural differences may influence relatives' needs. Relatives may also have unidentified needs, and these needs should be explored. Limited research has been carried out into interventions to meet relatives' needs and the effects of critical illness on their well-being, yet some relatives may experience negative psychological consequences far beyond the acute phase of the illness.

A phenomenological study to understand the experiences of nurses with regard to brainstem death

METHOD

In this study six nurses from general intensive care units were interviewed. The resulting transcripts were analysed using hermeneutic phenomenology.

FINDINGS

The findings fall into five categories, feelings, communication, protection, education, and technology. Nurses appear to suffer a degree of cognitive dissonance that both adds to their stress and leads to difficulties in explaining brainstem death to relatives.

CONCLUSION

Nurses need more education and support to enable them to overcome cognitive dissonance and so give relatives honest information. Verbal information should be supplemented with a written information leaflet given to all relatives.

An interdisciplinary team approach to evidence-based improvement in family-centered care

Family-centered care has become an integral part of total patient care in today's healthcare setting. Meeting family needs can be challenging for staff nurses already overwhelmed with escalating patient acuity and ever-increasing technical and documentation burdens. In the year 2000, an Interdisciplinary team in a tertiary hospital in the midwest employed a collaborative process to design and pioneer an award-winning nursing role in family-centered care. This article describes the methods used by this hospital to meet the ever-increasing challenge of family needs integrated into holistic patient care.

The experiences of families of critically ill patients in Greece: a social constructionist grounded theory study

BACKGROUND

The experiences of patients' families in intensive care units (ICUs) are of international concern. In Greece however, adequate attention has not been paid to this issue.

OBJECTIVE

To explore the experiences of critical care patients' families in Greece.

SETTING

The intensive care units of 3 general district hospitals in the area of Athens, Greece.

METHODOLOGY

The social constructionist version of grounded theory was used. In-depth interviews with 25 relatives of critically ill patients were carried out, and participant and non-participant observation was used to cross-validate the data obtained.

RESULTS

Seven major categories were identified, with 32 components across all categories. The experiences of families revolved around the two core categories of "Intense Emotions" and "Vigilant Attendance". The study conceptualised two new categories in this field, "Religiosity" and "Loss of Intimacy" and enhanced the category "Vigilant Attendance". Three further categories were identified, namely "Caring", "Dignity" and "Information". The various interrelationships between the categories were also examined.

CONCLUSIONS

The study has examined the experience of Greek patients' families from a qualitative perspective and suggests that major changes need to be made in terms of management and support.