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International Journal for Quality in Health Care Advance Access originally published online on April 10, 2008
International Journal for Quality in Health Care 2008 20(4):291-296; doi:10.1093/intqhc/mzn013
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© The Author 2008. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved

Arabic translation and adaptation of Critical Care Family Satisfaction Survey

Alison Brown1 and Mohammed Hijazi2

1 International Network for Cancer Treatment and Research, Rue Engeland 642, Brussels B-1180, Belgium
2 King Faisal Specialist Hospital and Research Center, PO Box 3354, Riyadh 11211, Saudi Arabia

Address reprint requests to: Alison Brown, International Network for Cancer Treatment and Research, Rue Engeland 642, Brussels B-1180, Belgium. Tel: +32-2-373-9323/9322; Fax: +32-2-373-9313; E-mail: alisonbrown40{at}hotmail.com


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Acknowledgements
 References
 
Objective. To translate and adapt the Critical Care Family Satisfaction Survey (CCFSS), and test its validity and reliability for use in Saudi Arabia.

Setting. Seven hundred-bed tertiary care hospital in Saudi Arabia.

Participants. Seventy-six adult relatives of patients who had been cared for in an intensive care unit for 24 hrs or more.

Interventions. The CCFSS, a battery of 20 items divided into five subscales, was translated into Arabic. After transfer of patients to regular inpatient units, interviewers administered the survey to their next-of-kin. Respondents ranked their satisfaction with each item on a 5-point Likert scale.

Main outcome measures. Subscale scores were calculated as the average of the individual item scores. The total scale score was the sum of the subscale scores.

Results. The total scale and ‘Information’, ‘Support’, ‘Comfort’ and ‘Assurance’ subscales showed acceptable internal consistency (Spearman's correlation coefficient of the total score with each of the subscale scores = 0.52–0.81, P < 0.01; Cronbach's alpha = 0.67–0.88). But the ‘Proximity’ subscale performed poorly (r = 0.48, P < 0.01; Cronbach's alpha = 0.36). Discriminant validity was tested with a Spearman's rank correlation matrix of the subscales, and ranged from weak between ‘Support’ and both ‘Assurance’ and ‘Information’ (r = 0.80) to substantial between ‘Information’ and ‘Proximity’ (r = 0.54) (P < 0.01).

Conclusion. This Arabic translation and adaptation of the CCFSS is a valid, reliable and feasible tool to evaluate family satisfaction in Saudi Arabian intensive care units.

Keywords: intensive care, quality improvement, surveys


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Acknowledgements
 References
 
Improvements in the quality and safety of patient care rely on the collection of accurate data. While the use of patient satisfaction information to identify areas for improvement is well established [1], family satisfaction is evaluated less frequently.

In the critical care setting, family involvement and support are particularly important. Evidence is accumulating that improvements in family satisfaction have a positive impact on patient outcome [2]. When relatives are given full and honest information in an understandable and timely manner, and believe that their family member is being treated with skill and compassion, satisfaction levels rise [3–7].

There are a number of validated tools available to measure family satisfaction and needs in the critical care setting. One of the most widely used is the Critical Care Family Needs Inventory. It was first developed in 1979 [5] and has been successfully tested in many different institutions since then, including after translation [4, 8, 9]. However, it is a very long tool with 45 need statements which respondents rate on a scale of one to four. In 2001, the development of two shorter questionnaires was reported in the medical literature [10, 11]. The validity of the latter, the Critical Care Family Satisfaction Survey (CCFSS), has been established both in the original hospital and in several other sites where it is being used on a regular basis [11–13]. It is a self-complete questionnaire with 20 statements which respondents are asked to rate on a 5-point Likert scale.

However, the patient and family populations in Saudi Arabia differ quite considerably from those in the United States. Distinctive sociocultural factors influence Saudi families' expectations and satisfaction with the ICU environment and delivery of healthcare [14]. Issues such as disclosure of diagnosis and prognosis, and discussions about termination of treatment are viewed differently as well [15, 16]. Therefore, it is essential to test the validity and reliability of any translation of a North American patient or family satisfaction questionnaire before using as a data collection tool in Saudi Arabia.

The aim of this study was to translate and adapt the CCFSS, and test its validity and reliability for use in a Saudi Arabian population.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Acknowledgements
 References
 
The CCFSS was translated into Arabic and then, to ensure accuracy, translated back into English by a second person. The two translators discussed the discrepancies and some changes were made in the Arabic version to rectify these. Finally, a third translator translated the revised Arabic questionnaire into English again for a last check. This version was then discussed with the staff responsible for administering hospital patient satisfaction surveys for their feedback. As a result of their suggestions, question 20 (‘Sharing in discussions regarding my family member's recovery’) was deleted and replaced with a question on the general appearance of the ICU staff. This was as an issue about which there had been a number of complaints. Modifications and final Arabic translation of the statements are presented in Table 1.


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  		Table 1. Arabic translation and adaptation of the Critical Care Family Satisfaction Survey

 
The CCFSS is in two parts. The first collects sociodemographic information: age of the respondent, number of days the patient was in the ICU and the relationship of the respondent to the patient. The second includes the 20 statements listed in Table 1, which the respondent is asked to grade on a 5-point Likert scale according to their satisfaction with that item. Responses are scored as follows: very satisfied = 5, satisfied = 4, not certain = 3, not satisfied = 2 and very dissatisfied = 1.

The study was conducted over a two-and-a-half month period in seven ICUs in a single tertiary care institution in Saudi Arabia. These included a neonatal, a paediatric, a cardiac surgery, a coronary care, two medical and a surgical ICU. Participating ICUs varied in size from 10 to 20 beds, with a nurse to patient ratio of one to one.

The study population consisted of one relative, 18 years or older, of patients who had been cared for in an ICU for at least 24 hrs. To improve comprehension and response rate, interviewers administered the survey and completed the form. The interviewers were Saudi employees who are trained to collect patient satisfaction data using structured questionnaires. They were also responsible for identifying eligible subjects. The interviewers contacted the relative following the patient's transfer to a regular inpatient unit. Participation was purely voluntarily. No pressure or inducement of any kind was applied to encourage an individual to participate in the study. All participants were informed of the project's Aim, Objectives and Methods. There were no patient or family member identifiers on the survey forms to encourage frank responses.

The data was analysed using SPSS software (version 10.0, SPSS Inc., Chicago, IL, USA). The responses were grouped according to the following five constructs and subscale scores calculated as follows:

  1. ‘Assurance’: summed scores for items 3, 4, 7, 19 and 20 were divided by 5,
  2. ‘Proximity’: summed scores for items 5, 15 and 18 were divided by 3,
  3. ‘Information’: summed scores for items 2, 6, 10 and 12 were divided by 4,
  4. ‘Support’: summed scores for items 1, 9, 11, 13, 14 and 16 were divided by 6,
  5. ‘Comfort’: summed scores for items 8 and 17 were divided by 2.
The overall satisfaction score was the sum of the subscale scores (range 5–25).

Internal consistency was tested by a Spearman's correlation coefficient of the total score with each of the five subscale scores. In addition, as a further measure of internal consistency, Cronbach's alpha was calculated for the total scale and each of the subscales. Discriminant validity was tested by a Spearman's rank correlation matrix of the subscales.

Incomplete questionnaires were dealt with as follows. If any question or questions were unanswered in a subscale, the score for that subscale was calculated as the mean response of the available items. If more than half of the questions were left unanswered the questionnaire was excluded.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Acknowledgements
 References
 
Over the period of the study, 76 questionnaires were completed. All had at least half of the questions answered. Therefore, none were excluded. Item response rates ranged from 100% for questions 1, 4, 6, 10, 14, 15 and 19 to 73.7% for question 17. Most of the other questions received good response rates (>96%) apart from questions 8 (75%) and 16 (77.6%).

More than half of the respondents (55.3%) were aged between 25 and 34, 26.3% between 35 and 59, 15.8% between 18 and 24, and only 2.6% 60 years or older. Most were members of the patient's immediate family, predominantly parents (46.1%) or offspring (30.3%) (Table 2). No wives were available for interview and husbands accounted for only 10.5% of the respondents.


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  		Table 2. Demographic characteristics of the respondents (n = 76)

 
The respondents reported that 72.7% of the patients had spent less than one week in the ICU and 17.1%, 10 or more days (Table 3). The largest number (34.7%) of these had been in the cardiac surgery ICU, followed by 25.3% in the medical and 22.7% in the surgical ICUs (Table 3). None were completed by respondents with a relative who had been in the neonatal unit.


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  		Table 3. Demographic characteristics of the patients (n = 76)

 
The mean total scale score was 20.5 (SD = 3.4) indicating that the majority of respondents were satisfied with the care their next-of-kin had received in the ICUs. Spearman's correlation as an index of internal consistency was highly significant at the 0.01 level with the total scale for all the subscales, and ranged from 0.48 for ‘Proximity’ to 0.81 for ‘Comfort’. The results are shown in Table 4. Cronbach's alpha was 0.88 for the total scale also indicating very good internal consistency. However, for the individual subscales Cronbach's alpha was more variable. The ‘Proximity’ subscale performed poorly (alpha = 0.36). ‘Assurance’ was better (alpha = 0.67). While the other three, ‘Information’, ‘Support’ and ‘Comfort’ showed good internal consistency (alpha ≥ 0.80) (Table 4).


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  		Table 4. Internal consistency correlations and Cronbach's alpha for subscales and total score (n = 76)

 
A Spearman's rank correlation matrix of the subscales provided statistically significant values at the 0.01 level between all but ‘Proximity’ and ‘Comfort’. Considering a correlation coefficient of <0.8 between subscales an indication of good discriminant validity, discriminant validity ranged from weak between ‘Support’ and both ‘Assurance’ and ‘Information’ (r = 0.80) to substantial between ‘Information’ and ‘Proximity’ (r = 0.54) (Table 5).


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  		Table 5. Discriminant validation diagonal matrixa (n = 76)

 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Acknowledgements
 References
 
The results of the study support the use of this Arabic translation and adaptation of the CCFSS as a tool to identify areas of satisfaction and dissatisfaction with patient care and family support in Saudi Arabian ICUs.

The respondent demographics differed from those of other published studies. A larger percentage (46%) was parents compared with ~9% in Heyland and Tranmer, and Wasser et al.'s [10, 11] studies. This figure reflects the composition of the general and patient populations in Saudi Arabia. Thirty eight percent of Saudis are under 14 years of age [17], and at any one time over 50% of the patients in the cardiac surgery ICU are paediatric. The results, therefore, support the use of the CCFSS for establishing family satisfaction with the care both paediatric and adult patients receive in the ICUs, which is important in Saudi Arabia.

There were some questions raised by the poor internal consistency statistics for the ‘Proximity’ subscale. This scale includes items on the ability to share in the care of the family member, privacy provided during visits and flexibility of the visiting hours. The interviewers reported a wide range of reactions from patients to the first question in particular. Some family members did not want any involvement in the hands-on care of their loved one, while others would have liked a great deal more opportunity to participate. It might be more useful for quality professionals using the data from this subscale to consider the responses to these three questions separately.

The second area where the questionnaire performed poorly was the substantial correlation between the responses to the ‘Support’ and ‘Information’, and ‘Support’ and ‘Assurance’ subscales indicating poor discrimination between these domains. A similar overlap was identified in Wasser et al.'s [11] first study when they tested the tool in an American population. They suggested that this could be explained by the inter-relationship between the areas. For example, level of satisfaction with some of the items in the ‘Support’ subscale depends on the quality of information given to the family, while others are dependant on their confidence in the skill of the ICU staff (assurance).

There were also several limitations to the study. First, the sample size was small, with not enough data from each individual ICU to test whether the CCFSS could identify unit-specific areas of dissatisfaction. This will be addressed by repeating the statistical calculations when there is more data available. Secondly, although seven ICUs were included in the study, there were no respondents from the neonatal and only two from the coronary care units, probably because patients are often discharged home rather than being transferred to a ward. Thirdly, inter-interviewer reliability was not investigated. An independent observer accompanied some of the interviewers to ensure they were using the exact wording of the items when administering the questionnaire but there was no rigorous testing performed. Fourthly, it was not possible to perform test-retest reliability checks, which requires administration of the survey a second time one week later to the same family member. Possible solutions to the last three problems will be explored.

In general, the results are very satisfactory and the total scale score may be used with confidence to monitor overall family satisfaction. However, the individual item scores appear to provide more useful information than the subscale scores in identifying areas for improvement. The survey tool may be modified in the future after further testing. Meanwhile, this Arabic translation of the CCFSS is a valid and reliable tool, feasible to administer, for collecting data to improve patient care and family support in Saudi Arabian ICUs. Based on these results, the study hospital has decided to use the CCFSS on a regular basis. It is hoped that healthcare professionals working in other Saudi Arabian and Arabic-speaking institutions will also find it helpful.


   Acknowledgements
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Acknowledgements
References
 
We particularly wish to acknowledge Jinan Al-Dihan and her staff for their assistance with interviewing the respondents and entering the data. We would also like to thank Shaima Alabdulgader for her enthusiastic contribution to the translation and administration of the survey.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Acknowledgements
 References
 

  1. Dodek PM, Heyland DK, Rocker GM, Cook DJ. Translating family satisfaction data into quality improvement. Crit Care Med (2004) 32:1975–6.[CrossRef][Web of Science][Medline]

  2. Dowling J, Wang B. Impact on family satisfaction: the critical care family assistance program. Chest (2005) 128:76–80.[CrossRef]

  3. Malacrida R, Bettelini CM, Degrate A, Martinez M, Badia F, Piazza J, Vizzardi N, Wullscheleger R, Rapin CH. Reasons for dissatisfaction: a survey of relatives of intensive care patients who died. Crit Care Med (1998) 26:1187–93.[CrossRef][Web of Science][Medline]

  4. Azouly E, Pochard F, Chevret S, Lemaire F, Mokhtari M, Le Gall J, Dhainaut JF, Schlemmer B. Meeting the needs of intensive care unit patient families: a multicentre study. Am J Respir Crit Care Med (2001) 163:135–9.[Abstract/Free Full Text]

  5. Molter NC. Needs of relatives of critically ill patients. Heart Lung (1979) 8:332–9.[Web of Science][Medline]

  6. Heyland DK, Rocker GM, Dodek PM, Kutsogiannis DJ, Konopad E, Cook DJ, Peters S, Tranmer JE, O'Callaghan CJ. Family satisfaction with care in the intensive care unit: results of a multiple centre study. Crit Care Med (2002) 30:1413–8.[CrossRef][Web of Science][Medline]

  7. Heyland DK, Rocker GM, O'Callaghan CJ, Dodek PM, Cook DJ. Dying in the ICU: perspectives of family members. Chest (2003) 124:11–2.[CrossRef][Web of Science][Medline]

  8. Bijttebier P, Delva D, Vanoost S, Bobbaers H, Lauwers P, Vertommen H. Reliability and validity of the Critical Care Family Needs Inventory in a Dutch-speaking Belgian sample. Heart Lung (2000) 29:278–86.[CrossRef][Web of Science][Medline]

  9. Lee IYM, Chien WT, Mackenzie AE. Needs of families with a relative in a critical care unit in Hong Kong. J Clin Nurs (2000) 9:46–54.[CrossRef][Web of Science][Medline]

  10. Heyland DK, Tranmer JE. Measuring family satisfaction with care in the intensive care unit: the development of a questionnaire and preliminary results. J Crit Care (2001) 16:142–9.[CrossRef][Web of Science][Medline]

  11. Wasser T, Pasquale MA, Matchett SC, Bryan Y, Pasquale M. Establishing reliability and validity of the Critical Care Family Satisfaction Survey. Crit Care Med (2001) 29:192–6.[CrossRef][Web of Science][Medline]

  12. Wasser T, Matchett S, Ray D, Baker K. Validation of a total score for the critical care family satisfaction survey. J Clin Outcomes Manage (2004) 11:502–7.

  13. Ray D, Wasser TE, Ahrens TM, Taylor RW, Ahrens TS, Thomas J, Owen C. Validation of the Critical Care Family Satisfaction Survey by use of internet data entry. 116-S. Crit Care Med (2006) 33. (Abstract Supplement).

  14. Auslander GK, Netzer D, Arad I. Parents' satisfaction with care in the neonatal intensive care unit: the role of sociocultural factors. Child Health Care (2003) 32:17–36.[CrossRef][Web of Science]

  15. Meleis AI, Jonsen AR. Ethical crises and cultural differences. West J Med (1983) 138:889–93.[Web of Science][Medline]

  16. Al-Shahri MZ. Culturally sensitive caring for Saudi patients. J Transcul Nurs (2002) 13:133–8.[CrossRef]

  17. Central Intelligence Agency. The World Factbook. https://www.cia.gov/library/publications/the-world-factbook/geos/sa.html (8 April 2008, date last accessed).

Accepted for publication March 5, 2008.


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