MD, PhD
ICU Nurse, Department of Critical Care Medicine, General Hospital of Larissa, Larissa, 2Associate Professor,
Faculty of Nursing, National and Kapodistrian University of Athens, Athens, 3Department of Intensive Care at
Agioi Anargyroi General Hospital, Athens, 4Consultant, Department of Intensive Care, General Hospital of
Larissa, Larissa, 5Professor, Faculty of Nursing, National and Kapodistrian University of Athens, Athens and
6
Principal Director, Department of Intensive Care, General Hospital of Larissa, Biomed/Cereteth, Research
Institution of Larissa, Larissa, Greece
1
Correspondence
Apostolos Komnos
Department of Intensive Care
General Hospital of Larissa
Axenidou 9
41222 Larissa
Greece
E-mail: akomnos@yahoo.com
Introduction
The main characteristics of health care include safety,
efficiency, effectiveness and equitability which should
be patient-centred in order to fulfil quality demands
(Mitchell 2008, Kourti et al. 2011). Patients experiDOI: 10.1111/jonm.12089
2013 John Wiley & Sons Ltd
S. Gerasimou-Angelidi et al.
Methods
Literature review
Client satisfaction is an important index for all services
provision, including hospital health care (Bull et al.
2000). In a large study, Aiken et al. (2012) calculated a
hospitals nurse staffing as the ratio of patients to nurses
and assessed the nurse work environment using the
Practice Environment Scale of the Nursing Work Index.
They found that, nurse staffing and work environment
were significantly related to patient satisfaction and
quality of care. Interestingly, better staffing was shown
to improve patient outcomes only if it was combined
with a good work environment (Aiken et al. 2011).
In general, a poor nurse work environment has been
linked to higher risk-adjusted mortality, increased
152
per shift) on that day. One nursing full-time equivalent per shift corresponds to the care of two patients
having a 50% score each. Thus, more than one nurse
can meet nursing requirements of a patient scoring
over 100% on a given day (Miranda et al. 2003).
One NAS point per cent is equal to 14.4 minutes per
24 hour or to 4.8 minute if the measurement of
nursing workload has been performed on an 8-hour
shift (Dias 2006, Giakoumidakis et al. 2009).
According to Miranda et al. (2003), the total time
consumed for nursing activities which are not evaluated by NAS is equal to 94.1 minutes in an 8-hour
shift. This category includes personal activities (e.g.
lunch break, toilet break) and activities that are not
assessed using the NAS instrument (e.g. activities
that are not related directly to the patient or are not
medical).
SAPS-II estimates the risk of death without specification of the primary diagnosis. SAPS-II includes 12
physiology variables, three underlying disease variables, type of admission and the patients age (Le Gall
et al. 1993). SAPS-II score ranges from 0 to 163
points. The calculation method results in a predicted
mortality, ranging from 0 to 100%.
In our physicians-led ICU, nursing staff consists
of 26 nurses. Eighteen nurses were university or
technological institute graduates (4-year curriculum)
whereas eight nurses were graduates from other nursing
schools (2-year curriculum). Five nurses had ICU or
emergency departments experience and 24 nurses in
internal medicine or surgical departments. Nurses
work in 8-hour shifts (morning shift 07:0015:00,
evening shift 15:0023:00 and night shift 23:00
07:00 hours), without on-call personnel available in
case of necessity. Nursing staff have multiple roles in
everyday practice:
S. Gerasimou-Angelidi et al.
154
sion model adjusted for SAPS II, patients age, LOS and
NAS with the Total Satisfaction Score (high/low) as a
dependent variable was applied. Statistical significance
was set at P < 0.05. The Cronbach a-value coefficient in
the present study was equal to 0.9, thus indicating a high
internal consistency (Ouzouni & Nakakis 2011).
Ethical considerations
The study protocol was approved by the Faculty of
Nursing, National and Kapodestrian University of
Athens (Number of Approval: 1217) and the hospital
local ethics committee. Written informed consent was
obtained from the family members.
Documentation for each of the 106 patients were
stored separately. Every participant was given a
unique serial number. This number was the only
combining factor for data collected during the study,
protecting the anonymity of the patients.
Results
Included in the study were 73 male and 33 female
patients with a mean age of 58.2 19.1 years (range
1888). The mean LOS was 19.3 24.7 days (range
2129) and the mean SAPS-II was 46.2 18.6 points
(range 796). Mortality during the study period was
12.3% (13 patients). Ninety-three patients (87.7%)
were discharged to other departments.
Family satisfaction
The mean total level of satisfaction calculated was
80.7% ( 9.6) (Table 2). Family members were more
satisfied with the level of care (91.8% 13.0) compared with decision making (65.2% 8.5). Higher
levels of satisfaction were reported regarding interest
and caring by ICU staff to the patient (96.1% 10.5),
nursing skill and competence (95.7% 11.9), interest
and caring given to family members (94.6% 16.1)
and pain management (93.9% 14.8). Participants
were less satisfied regarding the atmosphere of the depart 2013 John Wiley & Sons Ltd
Journal of Nursing Management, 2014, 22, 151158
Table 1
Demographics of family members according to family satisfaction
(FS) ICU-24
N
Gender
Male
Female
Total
Age
Mean SD 47.56 16
Minimum 18
Maximum 82
Relationship with the patient
Husband/Wife
Daughter
Son
Mother
Other
Total
First time of patient in ICU
Yes
No
Total
Live with the patient
Yes
No
Total
Frequency of visit at home
More than weekly
Weekly
Monthly
Less than once a year
Missing
Total
Location of stay
In the city
Out of town
Total
51
55
106
48.1
51.9
100.0
24
16
14
12
40
106
22.6
15.1
13.2
11.3
37.7
100.0
74
32
106
69.8
30.2
100.0
59
41
106
55.7
44.3
100.0
39
18
27
3
19
106
36.8
17.0
25.5
2.8
17.9
100.0
54
52
106
50.9
49.1
Nursing workload
Table 2
Family satisfaction (FS) subscales and total score
Mean (%) SD
(median)
Minimum Maximum
Satisfaction
106 91.79 13.04 (98.00) 26.10
with care
Satisfaction
106 65.22 8.45 (65.00)
38.44
with decision
making
Total
106 80.72 9.59 (83.00)
38.98
satisfaction
100.00
87.50
94.79
Discussion
According to the results of the present study, total
family satisfaction was high. Family members were
most satisfied with the level of care. Regarding nursing workload a shortage of nurses in the morning shift
was documented. A statistically significant positive
correlation between NAS and total satisfaction was
also found.
Recent studies showed several crucial factors related
to family satisfaction regarding ICU care: quality of
staff, overall quality of medical care, compassion and
respect to the patient and family, communication with
physicians, the waiting room and patient room
(Stricker et al. 2009, Rothen et al. 2010). Interestingly, high satisfaction rates with ICU services are not
unusual. Stricker et al. (2009) reported a TS24 of
78% 14 (satisfaction with care: 79% 14, satisfaction with information/decision making: 77% 15). In
a study conducted by Heyland et al. (2002), respondents scored >80% in overall care and >75% in decision making, whereas family members gave the
highest ratings for nursing skills and competence
(92.4% 14.0). A study performed by Kourti et al.
(2011) at a university ICU in Greece, demonstrated
scores of 7172.0%, 71.376.3% and 70.070.7% for
total satisfaction, care and decision making, respectively. Karlsson et al. (2011) reported that relatives
seemed to be quite satisfied with flexible visiting hours
and the quality of treatment, although they would like
155
S. Gerasimou-Angelidi et al.
Table 3
Association between NAS and total satisfaction: Logistic Regression Model
95% CI for EXP(B)
Age
SAPS II
LOS
NAS total
Constant
SE
Wald
d.f.
Sig.
0.012
0.018
0.005
0.128
4.169
0.012
0.014
0.009
0.064
2.218
0.878
1.592
0.252
4.050
3.534
1
1
1
1
1
0.349
0.207
0.616
0.044
0.060
Odds ratio
Lower
Upper
10.012
0.982
1.005
1.137
0.015
0.988
0.954
0.986
1.003
1.036
1.010
1.023
1.289
NAS, Nursing Activities Score; SE, standard error, d.f., degrees of freedom; CI, confidence interval; LOS, length of stay.
Table 4
Accessing nursing workload with a Nursing Activities Score (NAS)
per 8-hour shift
Shift
Morning
(07.0015.00)
Evening
(15.0023.00)
Night
(23.0007.00)
Total
score
physicians to be more available for regular consultation (up to 50% of participants had not fully understood information regarding diagnosis or options for
further care). Other authors have also noted that decision making is characterised by the lowest family satisfaction ratings (Azoulay et al. 2004, Pochard et al.
2005). In the study by Stricker et al. (2009), lower
overall satisfaction was linked to a higher nurse/
patient ratio, a finding also confirmed by Johnson et al.
(1998). Inadequate staffing tended to be inversely
related to family satisfaction and a nurse/patient ratio
of >3 was associated with lower satisfaction ratings
(Valentin & Ferdinande 2011).
NAS values in our study revealed a shortage of
nurses in the morning shift. Workload was estimated
at 6 hour and 51 minute. Therefore, each staff member had to work over 8 hours (8 hours and 22 minutes) given the time consumed for activities that are
not included in NAS items (Miranda et al. 2003). This
is in agreement with the high level of nurse burnout
156
Study limitations
The over-representation of traumatic brain injury and
cerebral strokes may create biases and thus should be
regarded as a study limitation. The regional distribution of units providing intensive care in Central
Greece may account for this imbalance, as the department is the only ICU performing thrombolysis in
the region. Additional research with larger samples
and more precise measurements of errors is also
suggested.
Conclusions
In the present study, we applied FS ICU-24 and NAS
in order to investigate the possible association
between nursing workload and family satisfaction.
Assessing family members satisfaction in critical care
settings may be quite complicated. An improvement in
clinical practice requires measurement of care quality
which includes family satisfaction. Our results indicated that family members were less satisfied with
decision making. An objective instrument, such as the
NAS, may add valuable information regarding the
2013 John Wiley & Sons Ltd
Journal of Nursing Management, 2014, 22, 151158
Acknowledgements
We would like to thank Dr George Krommidas for
statistical advice and Dr George Angelidis for editing
and linguistic review.
Source of funding
We would like to thank GlaxoSmithKline Pharmaceuticals for financial support of this work.
Ethical approval
Ethical approval was granted by No. 1217, National
and Kapodestrian University of Athens.
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