Abstract
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.
Keywords: Empathy, Need, Nurse, Family, Intensive care unit
Introduction
Quality improvement in healthcare requires a professional relationship between nurses, the clients, the relatives and other healthcare staff including physicians and nurses.1 These issues are growing in importance especially in intensive care units (ICU) for separation of relatives in threatening situations as well as decreased visit length that may disrupt the family equilibrium. Friedman states that this kind of dysfunction will have negative effect on other members.2 Moreover, following hospitalization of a patient, his/her family may experience extreme anxiety.3
One of the basic principles of the nursing process is that the care should be holistic, considering the patients, physical environment of ICU as well as the clients’ families.4 Developing a care program, nursing professionals would need to have comprehensive review of the family requirements. They also must prioritize the needs and provide an appropriate care for each person; such nursing requires empathy.5 Various studies have analyzed needs of patients’ relatives including need for hope, the correct information, and also they expect nurses to consider their feelings.
The term nursing empathy refers to the ability to perceive and share the feelings of client and the ability to communicate with them. It also is an empathic response to clients’ emotions and needs.6,7Effective communication is an integral component of empathy, in addition, good counseling is based on the ability to well communication with patients, but there has been little significant research on this concept.8 The few studies have also noted the essential role of empathy in nursing care for improving patients’ satisfaction and outcomes.9
In Iranian medical literature, few studies have investigated the nursing empathy with ICU patients, but there were no comprehensive study, reporting its association with the perceived needs of hospitalized patients’ family. However, few studies have separately investigated the requirements of ICU patients’ families or effectiveness of empathic nursing on patient outcomes.1 This study aimed to identify nurses’ empathy skills and its relationship with the needs of family members of patients admitted in ICU.
Materials and Methods
This cross-sectional study was conducted at four hospitals affiliated to Tabriz University of Medical Sciences (Sina, Emam Reza, Madani, and Shohada Training and Treatment Hospitals) in 2011. The study population consisted of family members of the patients admitted in ICUs of the study hospitals. The participants characteristics included age (ranged 18-65 years), physical and mental abilities to answer to the questions, first- degree relatives of the selected patient (spouse, father, mother, sibling, and children), admission of the patient in ICU (at least 48 hours, at most 10 days), and having at least a high school diploma.
A total of 418 relatives were entered into the study within 6 months by convenience sampling method. Similar to the most of descriptive studies, linear statistical method was used to determine the sample size. Accordingly, the sample size was 6-10 times larger than the number of questionnaire’s items.10 After selection of hospitals, their ICUs were selected as a stratified sample. The participants were then randomly selected based on admission order.
The data was collected using socio-demographic data form including family characteristics (age, gender, and familial relationship) and individual characteristics (age, gender, patient’s condition and history of admission). In this study, the Critical Care Family Needs Inventory (CCFNI) developed by Leske (1983) was used.11 The CCFNI is a 46-item with 4-point Likert scale in which higher score indicates greater need to care of family members. The second part of the questionnaire focused on the requirements of the clients and in the format of yes/no options. Barrett-Lennard Relationship inventory (BLRI) empathy scale was used to measure perceptions of the empathy developed by Layton and Weekly.12 The inventory consisted of 16 items with 6-point Likert scale (1 = very poor to 6 = excellent). The final score of the questionnaire ranged from 16 to 96; higher scores indicated more empathy on the system.
Prior to validity tests, the scale was translated. Accuracy of translation and face content validity were confirmed by 15 faculty members of Tabriz University of Medical Science. Cronbach’s alpha coefficient was calculated to measure the reliability of the scale and it was assessed on 30 participated family members. Accordingly, the Cronbach's alpha coefficient for the empathy and needs assessment questionnaire was 92% and 94%, respectively. The ethical approval was obtained from regional ethic committee and the faculty. After introducing himself to the authorities, the researcher attended the ICUs of the study hospitals every morning or evening. Individual consent was obtained after explaining the objects of the project and they were asked to complete the questionnaire. Data was analyzed using SPSS (version 13; SPSS Inc., Chicago, IL., USA). Descriptive statistics (frequency, percentage, mean and standard deviation) and inferential statistics (Pearson’s correlation, Friedman test and one sample Student’s t-tests) were used to analyze the results.
Results
The mean scores of empathy obtained by nurses were 63.9 (14.7). One sample t-test showed that the mean of the study data was so much higher than the median (56) and the difference was statistically significant (p= 0.001) indicating empathy between nurses and family of ICU patients (Table 1).
Table 1. Status of Barret-Lennard Empathy Scale in families of patients in intensive care unit .
| Empathy levels | Classification of empathy scores | N (%) |
| Very weak | 16-29.4 | - |
| Weak | 29.5-42.7 | 63 (15.1) |
| Middle | 42.8-56 | 61 (14.6) |
| Good | 56.1-69.3 | 112 (26.8) |
| Very good | 69.4-82.6 | 162 (38.8) |
| Excellent | 82.61-96 | 20 (4.8) |
| Mean (SD) | 63.9(14.7) |
The participants’ needs survey revealed that the mean score of CCFNI was 83.4 (34), that was less than the median (90).
The statistically significant difference between mean and median indicated that some needs were not being met for the relatives of hospitalized patients. Positive and significant relation between needs of the relatives and empathy score was observed (p = 0.001, r = 0.60).
The association between empathy and individual socio-demographic characteristics is presented in Table 2 suggesting significant association between patient age as well as clients’ needs and nursing empathy.
Table 2. The association of demographic characteristics with emphatic behaviors .
| Groups | N (%) | Mean (SD) | 95% CI | Statistical indicators | |
| Upper | Lower | ||||
| Gender of patient | |||||
| Male | 147 (35.2) | 65.3 (14.4) | 1.31 | -3.52 | t = 0.8, df = 1 p = 0.37 |
| Female | 271 (64.8) | 63.1 (14.8) | |||
| Gender of patient family | |||||
| Male | 254 (60.7) | 63.2 (14.7) | 2.87 | -1.88 | t = 0.4, df = 1 p = 0.68 |
| Female | 164 (39.3) | 64.9 (14.6) | |||
| Familial relationship | |||||
| Parents | 51 (12.2) | 69.9 (15.0) | 3.52 | -5.19 | t = 0.6, df = 3 p = 0.91 |
| Spouse | 67 (16.2) | 58.7 (16.3) | 2.20 | -4.55 | |
| Offspring | 148 (35.4) | 69.6 (12.3) | 3.62 | -4.02 | |
| Others | 152 (36.3) | 61.5 (14.8) | .. | .. | |
| History of admission | |||||
| Yes | 257 (61.4) | 66.2 (14.0) | 1.458 | -4.06 | t = 0.9, df = 1 p = 0.35 |
| No | 161 (38.6) | 60.2 (15.0) | |||
| Patient status | |||||
| Stable | 402 (96.1) | 64.1 (14.5) | 9.554 | -2.11 | t = 1.2, df = 1 p = 0.21 |
| Critical | 16 (3.9) | 57.8 (17.2) | |||
| Age of patient | |||||
| < 20 years | 60 (14.4) | 42.0 (20.0) | 0.70 | 0.25 | t = 3.6, df = 1 p < 0.001 |
| 21-40 years | 153 (36.6) | ||||
| 41-60 years | 115 (27.5) | ||||
| > 61 years | 90 (21.5) | ||||
| Age of the attendant | |||||
| < 20 years | 34 (8.1) | 33.9 (9.9) | 0.18 | 0.60 | t = 0.9, df = 1 p = 0.36 |
| 21-40 years | 293 (70.1) | ||||
| 41-60 years | 85 (2.3) | ||||
| > 61 years | |||||
| Needs | |||||
| < 40 | 34 (8.1) | 83.4 (34.0) | 0.33 | 0.26 | t = 14.8, df = 1 p < 0.001 |
| 41-80 | 204 (48.8) | ||||
| 81-120 | 63 (15.1) | ||||
| < 121 | 109 (26.1) | 109 (26.1) | |||
| CI: Confidence Interval | |||||
Discussion
Although most of the subjects rated the received nursing empathy as "very good", these patients had different priority needs. "Being informed of the treatments provided" was the most important perceived needs. The results of some other studies have emphasized the importance of informational needs of the patients that are often not met.13 A study conducted by Nelson et al. addresses the communication needs of this group.14 The results of the most of surveys represent unmet needs of relatives including "lack of information about the patients’ status" and "lack of explanations of the medical equipment being used in intensive care units".15
Regarding the findings of several studies families of patients admitted in ICU still have many unmet needs which are largely consistent with the results of our study. It should be noted that excessive stress experienced by the family members of ICU patients may disrupt their performance of daily life. On the other hand, improved compliance with existing status can be achieved by identifying the needs of this group.16
However, the findings on the empathy level of nursing professionals suggested high level of nurses’ empathy to the clients considering the issue from the viewpoint of the relatives. Dadkhah et al. conducted a survey on different aspects of empathic behaviors including empathic listening, verbal responses, communicating and maintaining behavioral flexibility and the results also revealed a positive empathic relationship between caregivers and patients. Thus, empathic communication is one of the key components in medical ethics.17
Some researchers believed that developed empathic sense should be included in primary care. Empathy is a key aspect to provide a tool for the evaluation of the quality of clinical care. It is also an emotional skill that enables caregivers to understand individual patient’s experiences and communicate in order to identify client’s concerns. It is necessary to integrate empathic communication skill into socio-professional process of recruitment.9
Furthermore, the results of current study determined positive and significant statistical association between empathy of nurses and family needs in admitted patients. A survey by Jenkins explored significant difference between perception of nurses and families.10However, based on a study conducted by Tietz, there was no significant relation between nurses’ empathy level and their ability to meet the needs of family members of the patients.13 In addition, only relatives of 15 patients participated in their study that could have affected their findings.
It should be noted that whenever the needs of ICU patients’ families are not met, they may not be able to provide optimal patient care or meet the needs of the ill member of the family. Regarding findings of our study, developing empathic responses of nursing staff towards families of ICU patients will also facilitate meeting the needs of this group of customers. It represents that registered nurses, nursing managers, and instructors should put an emphasis on elevating the virtue of empathy in nursing care.
Our study had some limitations. It evaluated nursing professionals’ empathy from family members’ perspective and nurses’ views were not taken into account. Moreover, all of the subjects had a high school diploma or higher education according to the inclusion criteria. It is recommended to perform more studies on perception of nurses and those with less than high school education. This study indicated positive and significant statistical relationship between nursing empathy and needs of patients' families that represented that the needs of the family members will be more effectively met by improving empathic skills among nurses.
Ethical issues
None to be declared.
Conflict of Interest
The authors declare no conflict of interest in this study.
Acknowledgments
Hereby, the authors would like to thank Tabriz Medical Science Research Deputy and Nursing and Midwifery that provided the financial support, and all the families participated in this study.
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