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Journal of Nursing Management, 2014, 22, 151158

Nursing Activities Score as a predictor of family satisfaction in

an adult Intensive Care Unit in Greece


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
Principal Director, Department of Intensive Care, General Hospital of Larissa, Biomed/Cereteth, Research
Institution of Larissa, Larissa, Greece

Apostolos Komnos
Department of Intensive Care
General Hospital of Larissa
Axenidou 9
41222 Larissa


(2014) Journal of Nursing Management 22, 151158.

Nursing Activities Score as a predictor of family satisfaction in an adult
Intensive Care Unit in Greece
Aim To study family satisfaction with care in an Intensive Care Unit (ICU) and its
association with nursing workload estimated by the Nursing Activities Score (NAS).
Background Few previous studies have investigated the association between
workload in ICUs and family satisfaction.
Methods Family Satisfaction ICU 24 (FS ICU-24) questionnaires were distributed to
161 family members (106 respondents). Questionnaires score, NAS measurements
and Simplified Acute Physiology Score II (SAPS-II) data were analysed.
Results The mean total level of family satisfaction was equal to 80.72% (9.59).
Family members were more satisfied with the level of care compared with
decision making. NAS values revealed a shortage of nurses in the morning shift.
Moreover, there was a statistically significant positive correlation between NAS
and total satisfaction after adjusting for age, length of stay and SAPS-II.
Conclusions Improvements in clinical practice require the measurement of care
quality which particularly includes family satisfaction. Our results indicated that
family members were less satisfied with decision making.
Implications for nursing management Nurse managers should plan for the
successful involvement of family members in the decision-making process. Higher
levels of nurse staffing might improve the care provided.
Keywords: critical care, family satisfaction, Intensive Care Unit, Nursing Activities
Accepted for publication: 1 March 2013

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

ence and health status are recognized as health care

outcome measures in terms of quality and quantity
(Griffiths et al. 2008). Nursing workload and adequate
staffing are also important parameters of health care
quality. Moreover, management interventions resulting
in favourable modifications of work environment lead

S. Gerasimou-Angelidi et al.

to improvements in nursing care. However, these

efforts usually have to overcome serious obstacles,
such as workforce shortages. The success of these
interventions is reflected in patient satisfaction as an
index of health care quality (Kutney-Lee et al. 2009).
The association between nursing workload and patient
satisfaction has been investigated in previous studies
(Pascale & Ayse 2008, Aiken et al. 2012).
Critically ill patients in Intensive Care Units (ICUs)
are unable to make decisions about their care (Ely
et al. 2004), or they usually rely on their family members to make decisions (Gooding et al. 2012). Given
the involvement of families as decision makers during
hospitalization, family satisfaction should be taken
into account when quality of care is assessed in the
ICUs (Wall et al. 2007a, Gerstel et al. 2008). Therefore, nursing care should be both family and patient
centred, adding another quality demand in the evaluation process (Hickman et al. 2012). Unfortunately, a
high incidence of conflicts between patients relatives
and staff members has been documented in previous
studies, such as teamfamily disputes, ineffective or
inappropriate communication by the health care team
and unclear or insufficient information (Davidson
2009, Roberti & Fitzpatrick 2010). he aim of the
present study was to explore family satisfaction with
care in an adult ICU in Greece and its association
with nursing workload. Family satisfaction was estimated by Family Satisfaction ICU 24 (FS ICU-24)
questionnaires and nursing workload was measured
by the Nursing Activities Score (NAS). A better understanding of the association between nursing workload
in the ICUs and family satisfaction may be of great
importance for nursing management, especially under
the present financial limitations of healthcare systems
as a result of austerity measures in many countries.

failure-to-rescue rates and worse patient outcomes

(Kutney-Lee et al. 2009). Moreover, promotion of the
work environment has been associated with lower rates
of nurse burnout and job dissatisfaction (Aiken et al.
In a critical care setting, nursing workload seems to
influence overall quality of care (Tucker 2002, Polderman et al. 2003). Also, staffing requirements increase
in parallel with nursing workload (Moura et al.
2011). During the last decades various scoring systems
have been used to measure nursing workload (Kalafati
& Paikopoulou 2006, Kiekkas et al. 2007). One of
the latest proposed scoring systems is NAS, created by
Miranda et al. (2003). However, the quality of care
depends on adequate staffing not only regarding the
number of nurses per shift but also regarding their
professional qualifications. Cutbacks in healthcare
usually affect both parameters (Ambrose 2002, Fawzi
2007). Costs regarding the employment of nursing
personnel account for about 50% of the total ICU
expenditure (Stricker et al. 2003, Cudak & Dyk
2010). Notably, Aiken et al. (2012) suggested that
efforts to improve the work environment may constitute a relatively low cost strategy in order to improve
Finally, given patients health status in the ICUs, relatives involvement is a crucial factor for health care
evaluation. Measuring family satisfaction may contribute to the assessment of care provided (Wall et al.
2007b) and family members may serve as important
evaluators in the complex process of improving ICU
care (Wall et al. 2007a, Gerstel et al. 2008). The association between family satisfaction and the health care
provided has been investigated in previous studies
(Heyland et al. 2002, Karlsson et al. 2011).

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

Setting and procedure

This retrospective study was carried out in our ninebed adult ICU of the General Hospital of Larissa, in
central Greece. Three evaluation tools were used in
the study: FS ICU-24, NAS and Simplified Acute Physiology Score II (SAPS-II).
The FS ICU-24 questionnaire is a reliable, validated,
widely available and well-tested tool for measuring
family satisfaction in the ICUs (Heyland & Tranmer
2001). It has been used in several Canadian and US
studies (Heyland et al. 2002, Curtis et al. 2008, Henrich et al. 2011, Lewis-Newby et al. 2011) and the
full questionnaire with instructions for researchers is
available online ( Also, FS
2013 John Wiley & Sons Ltd
Journal of Nursing Management, 2014, 22, 151158

Association of NAS and family satisfaction in ICU

ICU-24 has been translated into Spanish, German,

French and Greek. Validity of the FS ICU-24 Greek
version has already been validated by Malliarou et al.
FS-ICU 24 encompasses 24 items. Fourteen items
rate satisfaction of care, including two questions
regarding quality of care and quantity (frequency) of
nurses communication with family members. Ten
items evaluate satisfaction with decision making, such
as frequency, honesty, completeness and consistency
of given information and participation of family members in decision making. Participants select one of four
choices for each item. Each choice corresponds to a
percentage score, i.e. excellent or completely satisfied: 100%, very good or very satisfied: 75%, good
or mostly satisfied: 50%, poor or slightly dissatisfied: 25% and very poor or very dissatisfied: 0%
(N/A items are excluded) (Heyland et al. 2002, Wall
et al. 2007b). The total score for the 24 items (total
satisfaction, TS24) and subscale scores (satisfaction
with care or decision making) were calculated by averaging available items, provided that a participant
selects at least 70% of the 24 items. TS24 ranges from
0 to 100% (Wall et al. 2007b).
NAS measures nursing workload based on various
nursing intervention categories defined by Miranda
et al. (2003). NAS calculates a 24-hour total percentage score which corresponds to the time spent by
nurses on direct care, regardless of the severity of
the disease (Padilha et al. 2008). Measurement of an
8-hour workload is also possible, provided that there
is large number of shifts, the data are collected and
analysed per shift and there is no change in the items
defined (Miranda et al. 2003). NAS consists of 23
items: general nursing interventions (e.g. hygiene procedures and enteral feeding), specific nursing interventions (e.g. monitoring and titration and care of
artificial airways), administration of medications and
fluids, diagnostic procedures (e.g. laboratory), support and care of relatives and administrative or managerial tasks. Each item has a yesno answer,
except for items no. 1 (monitoring and titration), no.
4 (hygiene procedures), no. 6 (mobilization and positioning) and no. 8 (administrative and managerial
tasks) for which there are three different answers.
Each answer corresponds to a percentage (%) score,
which corresponds to different time-consuming nursing tasks in everyday practice. The total percentage
score is calculated by adding partial scores and
ranges from 0 to 177% (Miranda et al. 2003). A
patient scoring of 100% utilises the work of one
nurse per shift (or one nursing full-time equivalent
2013 John Wiley & Sons Ltd
Journal of Nursing Management, 2014, 22, 151158

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
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:

Nursing care organisation. In case of difficulties,

nurses may appeal to their head nurse or present
their concerns in regular ICU staff meetings.
Provision of patients care.
Support to the families. One aspect of family support includes consultation to family members. Family members can visit their relatives at noon for
1 hour and/or in the afternoon for 13 hour.
A combination of diagnostic procedures and aggressive treatments take place in the department, such as
neurosurgical interventions and hypothermia after cardiac arrest resuscitation. From January to the end of
December 2009, 161 patients were hospitalised. The
main disease categories were:

S. Gerasimou-Angelidi et al.

Diseases of the circulatory system (29.9%), average

length of stay (LOS) 19.2 days.
Diseases of the respiratory system (20.8%), average
LOS 16.2 days.
Diseases of the digestive system (14.3%), average
LOS 11.1 days.
Diseases by external causes (13%), such as multiply
injury and traumatic brain injury, average LOS
31.2 days.
Based on the following inclusion criteria, 106 of
161 patients were enrolled in the study:

Time of admission and discharge (transfer to other

department or death) during 2009. Seven patients
were excluded.
Presence of family members during ICU stay (first
visit within 24 hours after admission) and on the
day of discharge. No one was excluded.
ICU stay for more than 24 hours. Two patients
were excluded.
Respondents answers for the FS ICU-24 survey
were  70% of the respective items (Wall et al.
2007a). Forty-six patients were excluded.
Data collection methods
SAPS-II data were recorded on ICU admission by the
attending physician in charge and inserted into the
SAPS-II calculator provided by the OPUS 12 Foundation (an organisation that supports education and
research activities: The score was
automatically calculated and the extracted predicted
mortality was stored separately in our database. NAS
values were collected per shift. The nurse/patient ratio
was documented per day. The validated Greek version
of the FS ICU-24 questionnaire was distributed to family members by the attending physician on ICU discharge. Therefore, the whole period of ICU care was
evaluated by the participants. The attending physician
informed all participants regarding the confidentiality
of their responses and collected the questionnaires the
same day.
Data analysis
Data analysis for descriptive and inferential statistics
was performed using the Statistical Package for Social
Sciences for WINDOWS 17.0 (SPSS Inc., Chicago, IL,
USA). The satisfaction score for each FS ICU-24 subscale was dichotomized into relatively high and low
based on a median split. LOS and SAPS-II data were
used as covariates to investigate the possible association
between NAS and family satisfaction. A logistic regres-


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.

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.

Demographic of family members

Accordingly we included 106 participants (51 men, 55
women) in the FS ICU-24 survey (one family member
for each patient) with a mean age of 47.6 years. Seventy-four participants reported first-time ICU admission of their relatives. Twenty-four participants
reported a marital relationship with the patient and
59 that were living with the patient (Table 1).

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

Association of NAS and family satisfaction in ICU

Table 1
Demographics of family members according to family satisfaction
(FS) ICU-24
Mean  SD 47.56  16
Minimum 18
Maximum 82
Relationship with the patient
First time of patient in ICU
Live with the patient
Frequency of visit at home
More than weekly
Less than once a year
Location of stay
In the city
Out of town













Nursing workload

SD, standard deviation.

Table 2
Family satisfaction (FS) subscales and total score

model. Age, SAPS, LOS and total NAS were included

in the model as they are critical parameters for the
patients outcome and are linked to nursing workload.
NAS was the only variable that correlated significantly
with a high TS24 (P = 0.044). The probability of a
high TS24 increased by approximately 13.7% for
every NAS point increase (odds ratio 1.137; 95% confidence interval 1.0031.289) when the model was
adjusted for all other co-variables (Table 3).

Mean (%)  SD

Minimum Maximum

106 91.79  13.04 (98.00) 26.10
with care
106 65.22  8.45 (65.00)
with decision
106 80.72  9.59 (83.00)



SD, standard deviation.

ment or its waiting room (89.9%  17.3 and

81.6%  27.6, respectively).
When TS24 was dichotomized at 83% (median
value), the transformed variable was coded (low :
TS24  83 = 1, high : TS24 > 83 = 2) and applied
as the dependent variable in a logistic regression
2013 John Wiley & Sons Ltd
Journal of Nursing Management, 2014, 22, 151158

The average nurse/patient ratio was 1/2. The NAS

was calculated at 42.5%  6.2 for the morning shift,
36.6%  6.6 for the evening shift and 29.1%  6.7
for the night shift. The average workload calculated
was 36.1%  5.2. Therefore, given the above-mentioned nurse/patient ratio, the average workload per
shift/24 hours was 5 hours and 46.08 minutes,
whereas the workload calculated was 6.9 hours in the
morning shift (Table 4).

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

S. Gerasimou-Angelidi et al.

Table 3
Association between NAS and total satisfaction: Logistic Regression Model
95% CI for EXP(B)

NAS total










Odds ratio






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




Translating NAS into minute*

42.48% NAS 9 4.8= 3 hours 24 per patient
3 hours 24 9 2 = 6 hours 48 per nurse
(6 hours 48+ 1 hour 34.08 minutes =
8 hours 22)
36.62% NAS 9 4.8 = 2 hours 56 per patient
2 hours 56 9 2 = 5 hours 52 per nurse
(5 hours 52 + 1 hour 34.08 minutes =
7 hours 26)
29.05% NAS 9 4.8 = 2 hours 19 per patient
2 hours 19 9 2 = 4 hours 39 per nurse
(4 hours 39+ 1 hour 34.08 minutes =
6 hours 13)
36.05% NAS 9 4.8= 2 hours 53 per patient
2 hours 53 9 2 = 5 hours 46 per nurse
(5 hours 46+ 1 hours 34.08 minutes =
7 hours 20)

*Nursing time is equal to double the patients time as the nurse/

patient ratio is 1/2.

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

reported by a substantial proportion of Greek nurses

(Aiken et al. 2012).
Our findings regarding total family satisfaction and
satisfaction with care or decision making support
results from previous studies. Notably, we demonstrated that satisfaction with decision making was
characterised by lower ratings. Finally, in a model
adjusted for the severity of illness on admission (as
expressed by SAPS-II), LOS and age, we found that a
higher NAS was related to higher satisfaction. Possibly, intensity of care was highly appreciated by family
members and overwork was positively reflected in participants responses. This finding does not compensate
for the shortage of nurses but may underline the high
activity of the nursing staff.

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

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

Association of NAS and family satisfaction in ICU

association between nursing activity and family satisfaction.

Implications for nursing management

In accordance with the literature, we found that family satisfaction regarding decision making was rated
with lower scores, which may affect quality of healthcare. Therefore, nurse managers should develop more
effective strategies aimed at increasing the involvement
of family members in decision making. These initiatives could take place during the evening shifts as the
nursing workload is usually lower. Moreover, the
association between nursing workload and family satisfaction was found to be more complex than
expected. Additional factors, such as nursing overwork, seemed to influence these results. In spite of
limited financial resources, nurse managers should
take into account that an improvement in staffing levels may eventually have positive financial consequences by achieving favourable patient outcomes
through the prevention of adverse events.

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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