Australian Critical Care xxx (2017) xxx–xxx

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Australian Critical Care

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Review Paper
Families on adult intensive care units: Are they really satisfied? A
literature review
Cristóbal Padilla Fortunatti RN MSN (c)
Noelia Rojas Silva CNM MSN ∗
School of Nursing, Pontificia Universidad Católica de Chile, Avda, Vicuña Mackenna 4860, Macul, 7820436 Santiago, Chile

article information a b s t r a c t

Article history: Objectives: Family satisfaction in intensive care units (ICU) is of increasing relevance for family-centred
Received 29 March 2017 cared. The objective of this review was to explore the characteristics of studies that have used question-
Received in revised form 5 August 2017 naires to measure the satisfaction of family members of ICU patients.
Accepted 15 August 2017
Review methods: A literature review was performed for studies evaluating family satisfaction in the ICU,
independent of design. The following data were obtained for each selected article: publication year,
Keywords:
country of origin, design, number of family members, instrument for family satisfaction, instrument
Adult
score range, response rate, moment at which satisfaction was evaluated, and average level of reported
Family-centred care
Intensive care units
satisfaction.
Questionnaire research Data sources: The following databases were systematically searched: PubMed, CINAHL, ProQuest Nursing,
Surveys ProQuest Social Science, ProQuest Psychology, Science Direct, PsycINFO, LILACS, and Scielo.
Results: Thirty-seven articles met inclusion criteria, showing high levels of family satisfaction. Among
these, nine different questionnaires were identified. In 31.6% of the studies, family satisfaction was eval-
uated during the ICU stay, whereas 36.9% did not report the evaluation moment. The mean response rate
was 65.5%, and response rates greater than 70% were found only in 28.2% of the studies.
Conclusions: High satisfaction levels among family members of ICU patients must be contextualised in
light of questionnaire heterogeneity, low response rates, and variability in the moment at which family
satisfaction is evaluated. The creation of methodological standards for evaluating and reporting family
satisfaction could facilitate comparing results between investigations in this field.
© 2017 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction given in the ICU environment.3 Likewise, quality indicators focused

In the hospital context, the care of patients in critical condition
usually falls to the intensive care unit (ICU), which is characterised
by a highly technological environment, invasive treatments, and
patients who are many times unable to make their own decisions.1,2
Families of critical-care patients must face a situation that alters
family dynamics, all while handling the pressure of their loved one
often being in a life-threatening situation. Nevertheless, this expe-
rience does not have to be all negative for family members and can
be greatly improved by the quality of care given and concern shown
for the patient by the ICU team.
Due to the incorporation and evolution of concepts such as
family-centred care, healthcare institutions have progressively
adopted family satisfaction evaluations to assess the quality of care
∗ Corresponding author.
E-mail address: nprojas@uc.cl (N. Rojas Silva).
on the patient and their family are gradually receiving recognition
as performance measures in the ICU, which is in addition to tra-
ditional indicators centred on patient mortality or disease, such as
hospital-acquired infections.4 Nevertheless, while some countries
use family satisfaction as a quality indicator,5,6 no formal recom-
mendations currently exist regarding the minimum expected level
of satisfaction.7,8 This goes against the standards that a quality indi-
cator should possess, such as validity, reliability, allowing useful
comparisons, having a defined methodology for data collection, and
having an acceptable threshold.9,10
Research in recent years has reported high levels of family
satisfaction in the ICU.11–13 However, a deeper interpretation of
these findings requires characterising the measurement instru-
ments used and the specific aspects of each study. Critical analysis
is particularly relevant when considering that essential elements
can influence the results of the evaluated constructs, such as the
moment at which measurements are taken and the response rates
obtained by the investigators.14,15 In relation to this, Van den Broek

http://dx.doi.org/10.1016/j.aucc.2017.08.003
1036-7314/© 2017 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Padilla Fortunatti C, Rojas Silva N. Families on adult intensive care units: Are they really satisfied? A
literature review. Aust Crit Care (2017), http://dx.doi.org/10.1016/j.aucc.2017.08.003
2 C. Padilla Fortunatti, N. Rojas Silva / Australian Critical Care xxx (2017) xxx–xxx
et al.16 recently published a literature review that provides detailed
descriptions of the currently available instruments for measuring
the necessities and satisfaction of family in the ICU, with particu-
lar focus given to instrument quality on the basis of psychometric
properties. Notwithstanding this advancement, sufficient informa-
tion is not provided for establishing if family members are really
satisfied with ICU care.
1.1. Aim
The aim of this review was to explore the characteristics of stud-
ies that have measured satisfaction in family members of adult
ICU patients through the use of questionnaires. Specific investiga-
tive goals included determining the evaluation instruments used
for measuring family satisfaction, the representativeness of instru-
ment results measured by the response rates, and the moment
during hospitalisation at which family satisfaction was evaluated.
2. Methods
Between the months of September and December 2015, a liter-
ature review was performed for the following databases: PubMed,
CINAHL, ProQuest Nursing, ProQuest Social Science, ProQuest Psy-
chology, Science Direct, PsycINFO, LILACS, and Scielo. The keywords
“family satisfaction,” “intensive care unit,” “critical care,” “family,”
“ICU,” and similar MESH terms were used to conduct literature
searches. Studies included were those that reported general fam-
ily satisfaction in an adult ICU using a questionnaire. Studies were
excluded if the family members were related to newborn, paedi-
atric, end-of-life-care, or palliative-care patients; if qualitative in
nature; or if focused on validating a certain instrument. To define
the time of the review, a preliminary search was conducted in
Pubmed using the keywords “family satisfaction” and “ICU,” which
showed that the number of studies associated with this theme
began to increase between 2001 and 2002. This was the basis for
establishing a 15-year limit on studies included for review, with-
out restrictions on language. The Preferred Reporting Items for
Systematic Reviews (PRISMA) flowchart was used as a guideline
for the literature review process.17 The following information was
collected from each study: year of publication, country of origin,
design, number of family members, questionnaire for family sat-
isfaction, instrument score range, response rate, moment at which
satisfaction was evaluated during hospitalisation, and average level
of reported satisfaction.
As reported by the authors of the studies selected for review,
family satisfaction was examined at four time-points: a) Admis-
sion to ICU: from the moment of patient admission until transfer
out of ICU; b) Transfer: from the moment at which transfer is
decided and/or transfer effectively occurs; c) After discharge: from
the moment the patient is discharged from the healthcare facil-
ity or sometime thereafter, whether due to recovery or death; d)
Undefined: cases where the exact time of evaluation cannot be
accurately established, despite having information related to the
moment of evaluation; and e) Not reported: no mention is made as
to the moment of evaluation.
The response rate was used to evaluate the representativeness
of the results for each investigation. If not provided, the response
rate was obtained from the data given by each study. In cases where
studies evaluated more than one family group, only one sample was
considered for the literature review.
3. Results
The results of the literature search are shown in Fig. 1. A total
of 640 relevant articles were initially identified. Of these, 432
Please cite this article in press as: Padilla Fortunatti C, Rojas Silva N. Families on adult intensive care units: Are they really satisfied? A
literature review. Aust Crit Care (2017), http://dx.doi.org/10.1016/j.aucc.2017.08.003
duplicate articles were excluded, leaving 208 studies for potential
review. Based on the titles and abstracts of these articles, 155 did
not meet inclusion criteria, meaning that 53 articles were selected
for full-text evaluation. Ultimately, 37 articles were considered in
the present literature review, with the assessed data representing
8022 family members of ICU patients (Table 1).12,13,18–52
Eight studies (21.6%) included two samples of relatives, meaning
that final analyses were performed for 45 samples. Regarding study
design, 62.9% (n = 24) were descriptive cross-sectional studies, and
18.9% (n = 7) were associated with an intervention. In relation to
geographic distribution, 40.5% (n = 15) were performed in North
America; 21.6% (n = 8) were conducted in Europe, and the remain-
ing studies were mainly concentrated in Asia.
3.1. Applied instruments
A total of nine instruments were identified. These ranged from
original and modified versions of established instruments, as well
as self-created instruments (Table 2). The most used (35.1%) was
the 24-item version of the “Family Satisfaction in the Intensive
Care Unit” (FS ICU—24). Following with 18.9% and 13.5%, respec-
tively, were the short version of the “Critical Care Family Needs
Inventory” (CCFNI) modified by Johnson et al.53 and the “Critical
Care Family Satisfaction Survey” (CCFSS). Geographically, the FS
ICU—24 was most used in North America (46.7%), Asia (37.5%), and
Europe (37.5%), whereas the modified CCFNI was most used in Latin
America (75.0%).
3.2. Moment for evaluating family satisfaction
In 63.2% of the evaluated studies, family satisfaction was
assessed only once during hospitalisation (Table 3). More specif-
ically, 31.6% evaluated family satisfaction after the ICU admission
of the patient, 21.1% at the moment of transfer, and 10.5% after dis-
charge. The moment when family satisfaction was evaluated was
unclear in 36.9% of the studies, with most of these cases (56.3%)
being from North America. In contrast, over 75% of the studies con-
ducted in Asia and Latin America defined the moment at which
family satisfaction measurements were taken during the ICU stay.
3.3. Response rate
Among the included studies, the mean response rate was 65.5%,
with the highest response rates coming from Latin America (79.8%)
and Asia (79.3%), while North America (54.7%) had the lowest
response rates (Table 4). A response rate greater than or equal to
70% was recorded for 29.7% of the included reports. The geographic
regions with the lowest proportion of studies to meet this last cri-
terion were North America (6.7%) and Europe (37.5%). Studies that
did not cite the response rate or could not be obtained accounted
for 27.0% of the included literature.
4. Discussion
The objective of this literature review was to identify the char-
acteristics of studies that have measured the satisfaction of family
members of adult ICU patients through the use of questionnaires.
Family satisfaction is a subject of increasing interest to the health-
care area, with North America leading, in terms of quantity of
research related to this topic. Consequently, more instruments
that measure family satisfaction have been created and validated
in North America.16 In contrast, the literature also includes stud-
ies that measure family satisfaction but do not consider adequate
instrument translation, cultural adaptation, or validation processes,
making reliable comparisons difficult.54 This situation is partic-
ularly recurrent in countries where a lower frequency of family
literature review. Aust Crit Care (2017), http://dx.doi.org/10.1016/j.aucc.2017.08.003
Please cite this article in press as: Padilla Fortunatti C, Rojas Silva N. Families on adult intensive care units: Are they really satisfied? A

Table 1
Summary of reviewed articles.

Author Design Location N Questionnaire Minimum Maximum Subgroup Family satisfaction

score score score (mean)

Aboumatar et al.18 Cross sectional North America 41 FS ICU 24 0 100 89

Abvali et al.19 Quasi experimental Asia 38 FS ICU 24 0 100 32,7
Auerbach et al.20 Longitudinal North America 40 CCFNIa 56 14 24,7
Burns et al.21 Non randomized North America 403 SEQ 1 6 4,4
controlled trial
Carlson et al.22 Cross sectional North America 29 FS ICU 34a 0 4 3,28
Damghi et al.23 Cross sectional Africa 194 CCFNIa 56 14 29
Dodek et al.24 Cross sectional North America 339 FS ICU 24 0 100 Nonsurvivors 78,2
512 FS ICU 24 0 100 Survivors 78,1
Emlet et al.25 Interrupted time series North America 57 CCFNI 57 18 24,0

C. Padilla Fortunatti, N. Rojas Silva / Australian Critical Care xxx (2017) xxx–xxx
trial
Freitas et al.26 Cross sectional Latin America 44 CCFNI 1 4 Private hospital 3,2
47 CCFNI 1 4 Public hospital 2,9
27
Fumis et al. Cross sectional Latin America 164 CCFNIa 0 14 10,8
Fumis et al.28 Cross sectional Latin America 471 CCFNIa 0 14 12,4
Gajic et al.29 Before–after intervention North America 84 CCFSS 22 4 5,9
Garland et al.30 Cross over pilot trial North America 60 FS ICU 24 0 100 73,3
Gerasimou-Angelidi et al.31 Cross sectional Europe 106 FS ICU 24 0 100 80,7
Hagerty et al.32 Cross sectional North America 23 FS ICU 24 5 1 Spanish-speaking 2,8
50 FS ICU 24 5 1 English-speaking 2,2
33
Hajj et al. Cross sectional Asia 123 CCFSS 5 25 20,9
Heyland et al.34 Cross sectional North America 624 FS ICU 0 100 80,2
Holanda Peña et al.35 Cross sectional Europe 190 FS ICU 34 0 100 Survivors 79,6
31 FS ICU 34 0 100 Nonsurvivors 74,2
Jacobowski et al.36 Before–after intervention North America 98 FS ICU 24 0 100 Survivors 85,0
18 FS ICU 24 0 100 Nonsurvivors 74,0
37
Jongerden et al. Before–after intervention Europe 323 FS ICU 34a 0 100 Single room ICU 69,5
Karlsson et al.12 Cross sectional Europe 35 CCFSS 0 100 86,6
Khalaila38 Cross sectional Asia 70 FS ICU 24 0 100 73,7
Kodali et al.39 Secondary data analysis North America 108 FS ICU 24 0 100 Family meeting (+) 84,2
120 FS ICU 24 0 100 Family meeting (−) 80
Lam et al.40 Cross sectional Asia 736 FS ICU 34 0 100 78,1
López et al.41 Quasi experimental Europe 50 FS ICU 24 0 100 80,20
Mosleh et al.42 Cross sectional Asia 246 FS ICU 24 0 100 72,5
Neves et al.43 Cross sectional Latin America 53 CCFNIa 56 14 26,2
Omar et al.44 Cross sectional Asia 139 CCFNIa 56 14 Fast track (−) 17,9
116 CCFNIa 56 14 Fast track (+) 18,1
Roberti and Fitzpatrick45 Cross sectional North America 31 CCFSS 0 100 94,1
Schwarzkopf et al.13 Cross sectional Europe 215 FS ICU 34a 0 100 78,3
Shaw et al.46 Before–after intervention North America 67 FS ICU 24 0 100 83,2
Steel et al.47 Time-interrupted Europe 79 CCFSS 1 5 4,50
prospective trial
Stevens et al.48 Cross sectional North America 123 FS ICU 34 0 100 Summer 67,0
North America 413 FS ICU 34 0 100 Rest of the year 66,0
Stricker et al.49 Cross sectional Europe 996 FS ICU 24 0 100 78,4
Sundarajan et al.50 Cross sectional Australia 84 SEQ 0 10 8
Venkataraman et al.51 Cross sectional Asia 200 FS ICUa 0 100 94,5
Yousefi et al.52 Quasi experimental Asia 32 CCFNIa 0 42 19,3

Note: FS ICU—24 = Family Satisfaction in the Intensive Care Unit—24; CCFNI = Critical Care Family Needs Inventory; CCFSS = Critical Care Family Satisfaction Survey; FS ICU—34 = Family Satisfaction in the Intensive Care Unit—34;
FS ICU = Family Satisfaction in the Intensive Care Unit; SEQ = Self elaboration questionnaire.
a
Modified versions of the original questionnaires.

3
4 C. Padilla Fortunatti, N. Rojas Silva / Australian Critical Care xxx (2017) xxx–xxx

Fig. 1. PRISMA Flow diagram for screening and selection of articles for inclusion.

Table 2
Geographical distribution and type of questionnaires used to evaluate family satisfaction.

Instrument North America Europe Asia Latin America Australia Africa Global

Family Satisfaction in the Intensive Care Unit—24 (n) 46,7% (7) 37,5% (3) 37,5% (3) – – – 35,1% (13)
a
Critical Care Family Needs Inventory (n) 6,7% (1) – 25,0% (2) 75,0% (3) – 100,0% (1) 18,9% (7)

Critical Care Family Satisfaction Survey (n) 13,3% (2) 25,0% (2) 12,5% (1) – – – 13,5% (5)

Family Satisfaction in the Intensive Care Unit—34 (n) 6,7% (1) 12,5% (1) 12,5% (1) – – – 8,1% (3)
a
Family Satisfaction in the Intensive Care Unit—34 (n) 6,7% (1) 25,0% (2) – – – – 8,1% (3)

Critical Care Family Needs Inventory (n) 6,7% (1) – – 25,0% (1) – – 5,4% (2)

Self-elaboration questionnaire (n) 6,7% (1) – – – 100,0% (1) – 5,4% (2)

Family Satisfaction in the Intensive Care Unit (n) 6,7% (1) – – – – – 2,7% (1)

Family Satisfaction in the Intensive Care Unit* (n) – – 12,5% (1) – – – 2,7% (1)
a
Modified versions of the original questionnaires.

satisfaction studies has been reported. For example, although Latin
America is predominantly comprised of Spanish-speaking coun-
tries, the review by van den Broek et al.16 only included studies
from Brazil. Furthermore, studies are reported in which a Spanish-
translated version of the FS ICU—24 has been used,32,41 but there
is no evidence for a prior validation process. The lack of this pro-
cess not only prevents establishing the degrees of instrument
validity and reliability, but also the conceptual equivalence of
translations.54 Currently, the only validated instrument in this
language is the short version of the CCFNI, as reported by Gómez-
Martínez et al.55
The current literature review identified a total of nine instru-
ments, which presented differences in the measurement scale for
Likert responses. This finding aligns with the review by van den
Broek et al.,16 who reported that among a total of 27 question-
naires used for family satisfaction evaluations, 11 were versions of
the FS ICU and 10 were variants of the CCFNI. Although modifica-
tions to original instruments can be used to respond to the distinct
objectives of each investigation, only the FS ICU-24 and CCFNI
are supported by adequate psychometric properties, whereas the
versions of the different remaining instruments have not been ana-
lysed in depth.
A large part of the included studies reported average satisfac-
tion levels near the maximum possible, indicating the probable
presence of the ceiling effect. In these cases, family groups with
the highest scores cannot be differentiated from one another, thus
decreasing result reliability and limiting the ability of the instru-
ment to expose aspects that could be improved or to measure the

Please cite this article in press as: Padilla Fortunatti C, Rojas Silva N. Families on adult intensive care units: Are they really satisfied? A
literature review. Aust Crit Care (2017), http://dx.doi.org/10.1016/j.aucc.2017.08.003
 C. Padilla Fortunatti, N. Rojas Silva / Australian Critical Care xxx (2017) xxx–xxx
Table 3
Geographical distribution of the moment of evaluation of family satisfaction.
Moment of evaluation North Americaa Europe Asia
Admission to ICU (n) 6,3% (1) – 87,5% (7)
Transfer (n) 25,0% (4) 37,5% (3) – –
After discharge (n) 12,5% (2) 25,0% (2) – –
Undefined (n) 43,8% (7) 12,5% (1) 12,5% (1)
Not reported (n) 12,5% (2) 25,0% (2) – 25,0% (1)
a
Dodek et al.24 reports family satisfaction in 2 moments.
Table 4
Geographical distribution of the studiesı́ response rate.
Response rate North Americaa Europea
Mean response rate (SD) 54,7% (14,8) 64,2% (21,2)
Studies with a response rate >70% (n) 6,3% (1) 33,3% (3)
Studies with a response rate <50% (n) 18,8% (3) 33,3% (3)
Studies with no response rate reported (n) 18,8% (3) 11,1% (1)
a 36 36
Jacobowski et al. & Holanda Peña et al. reported separated response rates for both relative samples.
impact of improvement initiatives.56,57 On the other hand, no con-
sensus exists as to the threshold for defining if a family member
is satisfied. In a study performed in Brazil, which used the short
version of the CCFNI, family members were deemed satisfied based
on the first-quartile scores of a previous investigation.58 Similarly,
Huffines et al.59 established satisfaction when 90% or more of the
family members scored each item of the CCFSS with the maximum
satisfaction score possible. Some authors classify family members
as satisfied if maximum scoring is achieved on the respective Lik-
ert scale and as unsatisfied if any other responses are given.11,32,36
Using these Likert scale-based criteria, Hunziker et al.60 classified
family members as less than fully satisfied.
Another way to determine family satisfaction in the ICU is to
dichotomise family members as satisfied or unsatisfied according
to the Likert-scale of each instrument. Applying the CCFNI, Fre-
itas et al.26 reported that the needs were satisfied as the obtained
points were reported as satisfied or very satisfied; Azoulay et al.61
and Neves et al.43 used the same criteria in the short version of the
CCFNI. Despite this sort of classification appearing practical and
logical, the results of family satisfaction questionnaires in the ICU
are normally based on the summed score of questionnaire items,
with the same relative weight given to certain aspects known to
be of unequal importance to the family, such as environment vs
information or comfort vs decision making.62 This variability could
mean that overall questionnaire results find family members to be
satisfied despite having low scores for items of significant impor-
tance.
While an abundant amount of literature exists for evaluating
family satisfaction in the ICU, no consensus or formal definition
exists regarding certain methodological aspects of the evalua-
tion process. For example, notable heterogeneity exists regarding
the moment at which family satisfaction is measured during the
hospital stay. One of the few transversally assessed criterion, in
terms of needs and family satisfaction, is the minimum time needed
to invite family members to participate in research of this type,
varying between 48 and 72 h after patient admission and when a
minimum comprehension of and exposure to the ICU environment
is acquired.23,40,63 According to the Double ABCX Model of Adjust-
ment to Family Stress developed by McCubbin and Patterson,64
adaptation to a critical event occurs progressively over time.
Therefore, family satisfaction should be understood as a dynamic
construct since the results could be affected by the time that has
Please cite this article in press as: Padilla Fortunatti C, Rojas Silva N. Families on adult intensive care units: Are they really satisfied? A
literature review. Aust Crit Care (2017), http://dx.doi.org/10.1016/j.aucc.2017.08.003
5
Latin America Australia Africa Global
75,0 (3) – 100,0% (1) 31,6% (12)
100,0% (1) – 21,1% (8)
– – 10,5% (4)
– – – 23,7% (9)
– – 13,2% (5)
Asia Latin America Australia Africa Global
79,3% (12,3) 79,8% (6,1) – 82,3% (0) 65,5% (19,1)
50,0% (4) 50,0% (2) – 100,0% (1) 28,2% (11)
– – – – 15,4% (6)
37,5% (3) 50,0% (2) 100,0% (1) – 25,6% (10)
passed between patient admission to the ICU and when satisfaction
is evaluated.
The most frequent moment for evaluating family satisfaction
according to the selected literature was during the ICU stay. How-
ever, the length of stay for critical-care patients also determines
distinct degrees of family exposure and adaptation. The moment at
which family satisfaction is measured should be a factor considered
at the moment of interpreting results for the ICU,23,37 particularly
for North American studies as more than half of the existing reports
did not explicitly define when the satisfaction questionnaire was
administered. Regarding this, Casarett et al.65 proposes that family
satisfaction could be evaluated soon after patient death; however,
the early stages of grief are associated with periods of denial and
insensitivity, which could affect the ability of family members to
objectively evaluate the care given. Research results on a satisfac-
tion survey administered to the parents of paediatric patients also
support that the moment of administration can impact response
rate.66 Crow et al.67 suggests that evidence for the impacts of evalu-
ation moment on satisfaction are contradictory, possibly depending
on the nature of the disease and recovery time. Similarly, some
family satisfaction questionnaires are given when the patient is no
longer in the ICU or even the same hospital, meaning that the results
could be influenced by experiences outside of the ICU.40 The differ-
ences observed in regard to the moment of evaluation also mean
that other factors, such as service charges or a change in patient
status, affect the perception of satisfaction.68
One important event during the stay of a patient and their
family in the ICU is that of patient transfer to units of less com-
plexity. These units often have lesser degrees of personalised
attention and monitoring elements, many times translating into
anxiety, insecurity, and mistrust,69 possibly affecting the objectiv-
ity of family members when answering satisfaction questionnaires.
Additionally, in 68.4% of the included studies, family satisfaction
was not evaluated in the ICU, meaning that results might not be
representative of the attention received solely in this unit. Given
the impact that the moment of evaluation could have on family
satisfaction, longitudinal studies would better facilitate analyses
on the evolution of family satisfaction over time, particularly when
evaluations have been administered early during the ICU stay.19 A
longitudinal study by Auerbach et al.20 found no significant differ-
ences in family satisfaction levels when evaluated 3 days after ICU
admittance and at discharge from the ICU, an average of 30 days
6 C. Padilla Fortunatti, N. Rojas Silva / Australian Critical Care xxx (2017) xxx–xxx
after patient admission. Nevertheless, differences in satisfaction
were reported for needs related to the clarity of information and
comfort when visiting the patient.
An additional aspect worth considering is the response rates
reported by researchers. Although there is no consensus as to what
an acceptable response rate should be for studies reporting on the
use of questionnaires, some minimum values have been proposed,
such as 60%,70 75%,71 and even 80%.72 The variations in response
rate found in the present literature review are in line with results
from an extensive review that evaluated 210 studies on patient
satisfaction; a review in which only 48% of studies reported the
response rate and 25% of which gave no explanation for exclud-
ing response-rate data.72 However, patient satisfaction studies do
indicate that self-administered questionnaires are related to low
response rates,72 but even when some of the authors included in
the current literature review expressed concern about response
rates, none deeply explored the reasons for which family groups
did not participate or the effect of response rate on the results.
Similarly, differences in the sociodemographic profiles of respon-
ders and non-responders could affect the reported response rates.
Although none of the evaluated studies described the sociode-
mographic traits of non-responders, variables such as gender,
ethnicity, age, and type of health coverage have been previously
associated with low response rates.73,74 These data, particularly for
non-responders, should be considered when interpreting satisfac-
tion levels.
Given this situation, the high levels of reported satisfaction
could be indicative of a selection bias as family members who could
not be contacted or who refused to participate might hold opinions
different to those who responded to the questionnaires.36 Even
with acceptable response rates, family members who responded
could have different opinions than those members that did not
respond, thereby creating biased responses that might influence
satisfaction levels.33 Additionally, one of the preferred methods for
inviting questionnaire participation among family members in the
ICU is through personal contact, which could increase the levels
of reported satisfaction as an effect of social desirability, i.e. fam-
ily members might express greater satisfaction than truly felt in a
search for acceptance by the researcher.72
5. Conclusion
High satisfaction levels exist among the family members of adult
ICU patients. However, the validity of these results needs to be
considered in the contexts of study heterogeneity and the lack
of information regarding some methodological aspects. Question-
naire diversity, a lack of formal validation processes, low response
rates, and variability in the moment at which family satisfaction
is measured are all aspects that limit ensuring that family mem-
bers of ICU patients are really satisfied and, if so, to what degree.
Standardising the evaluation and reporting methods for family sat-
isfaction in the ICU could be the first step in allowing for meaningful
comparisons between studies on this subject.
Authors’ contributions
All authors substantially contributed to review concept and
design; the collection, analysis, and interpretation of data; and
drafting and critical revision of the manuscript. The final version
of the manuscript was approved by all authors prior to submission.
Funding
This study received financial support for its translation by the
Investigation Department of the School of Nursing at the Pontificia
Universidad Catolica de Chile.
Please cite this article in press as: Padilla Fortunatti C, Rojas Silva N. Families on adult intensive care units: Are they really satisfied? A
literature review. Aust Crit Care (2017), http://dx.doi.org/10.1016/j.aucc.2017.08.003
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