MA Al-Hassan and IM Hweidi

International Journal of Nursing Practice 2004; 10: 64–71

✠ RESEARCH PAPER ✠

The perceived needs of Jordanian families of

hospitalized, critically ill patients
Musa Ali Al-Hassan RN PhD
Assistant Professor, School of Nursing, Jordan University of Science and Technology, Irbid, Jordan

Issa M Hweidi RN DNS

Assistant Professor, School of Nursing, Jordan University of Science and Technology, Irbid, Jordan

Accepted for publication August 2003

Al-Hassan MA, Hweidi IM. International Journal of Nursing Practice 2004; 10: 64–71
The perceived needs of Jordanian families of hospitalized, critically ill patients

The purpose of this study was to identify needs of Jordanian families of hospitalized, critically ill patients. The Critical Care
Family Needs Inventory was introduced to 158 family members who were visiting their hospitalized, critically ill relatives.
The findings revealed that ≥ 80% of the family members perceived 16 need statements as important or very important.
The participants ranked order needs for assurance, information and proximity the highest and needs for support and com-
fort the lowest. Specifically, the most important needs of the families were to receive information about the patients, to
feel that the hospital personnel care about the patients and to have the information given in understandable terms. Results
of this study indicated that Jordanian families had specific and identifiable needs. Providing families of critically ill patients
clear, simple and updated information about the patients, and assuring them about the quality of care the patients receive,
should be essential components of the critical care nursing delivery system.
Key words: critically ill, family needs, Jordan.

INTRODUCTION despair, helplessness and frustration.6 If unresolved, these

A critical illness of a family member has been recognized
as a life-threatening event that comes without warning,
allowing little time for families to adjust.1 The critical ill-
ness and hospitalization in critical care units (CCUs) are
considered important stressors2 that induce role alter-
ations, disorganization and fragmentation of families.3–5
The families might experience a psychological crisis in
which new needs emerge. Emotional responses of family
members of hospitalized, critically ill patients include
Correspondence: Musa Al-Hassan, Assistant Professor, School of Nurs-
ing, Jordan University of Science and Technology, Irbid, Jordan, PO Box
3030. Email: alhassan@just.edu.jo
responses adversely affect the families’ well-being7 and,
subsequently, patients’ health.8 Nurses need to under-
stand the families’ experiences and identify their needs
associated with hospitalization of critically ill members.
This knowledge is essential to optimize families’ well-
being and coping, so that they can provide appropriate and
effective support to their critically ill members. The prac-
tice of holistic care implies that nurses consider needs of
patients and their family members.9 Therefore, it is crucial
that nurses assess families’ needs during hospitalization of
their ill relatives and measure whether or not these needs
are being met.
The health care system in Jordan consists of three sec-
tors: private, military and public. The public health care
Needs of families of critically ill patients
sector provides care for the vast majority of Jordanians at
low cost. It is primarily composed of community health
care centres and acute health care institutions. The visiting
policy of all public hospitals limits visiting hospitalized
patients to 2 h (14.00–16.00 hours) during working days
and in the morning of weekend days. Families of very crit-
ically ill patients are allowed to be with their relatives for
limited intervals throughout the day. The public hospitals
do not include waiting rooms for visitors, although it is
usual that a reasonable number of relatives and friends
visit the sick, especially the critically ill.
In Jordan, visiting the sick represents a favourable
social act that is culturally encouraged. In this country,
various factors might interact to shape the culture of social
relations and, undoubtedly, Islam and family structure are
the most influential factors. Although the Jordanian peo-
ple appreciate the western way of living, an extended fam-
ily type dominates the Jordanian culture. In this type of
family, elderly are regarded with high respect, strong
bonds among the family members are appreciated and
required, and providing support to families of ill members
is highly encouraged. Islam is also influential in shaping the
interpersonal relationships of the Moslems. It is expressed
in most daily activities of the people. Islamic teachings and
laws are basically derived from two sources, the Noble
Qur’an and Sunnah (sayings, deeds and sanctions of the
Prophet Mohammed).10 Both sources encourage visiting
the sick and providing emotional and tangible support to
others. A common saying for the Prophet Mohammed is
that a Moslem to another Moslem is like one body; if an
organ complains, the other organs respond with insomnia
and fever. In other words, provision of support and main-
tenance of strong bonds among people are highly encour-
aged in the Jordanian culture.
In western culture, the needs of families of hospital-
ized, critically ill relatives have been described as many
and variable.5 In Jordan, the needs of families of critically
ill patients have never been described. The purpose of this
study was to identify needs of Jordanian family members
during hospitalization of their relatives in CCUs.
LITERATURE REVIEW
A family need has been defined as ‘a requirement, which if
supplied, relieves or diminishes their distress or improves
their sense of adequacy and well-being’.8 Research has
confirmed the existence of specific and identifiable needs
of families of hospitalized, critically ill patients. Molter
developed a list of 45 need statements and introduced
65
them to 40 family members of critically ill patients to rate
their importance.11 The top 10 needs identified by the
family members were:
1. To feel that there is hope.
2. To feel that hospital personnel care about the patient.
3. To have a waiting room near the patient.
4. To be called at home about the patient’s condition.
5. To know the prognosis.
6. To have questions answered honestly.
7. To know specific facts about the patient’s prognosis.
8. To receive information about the patient once per
day.
9. To have an explanation given in understandable
terms.
10. To see the patient frequently.
Leske8 randomly changed Molter’s need statements and
added an additional, open-ended question to identify new
needs, naming the resulting instrument the Critical Care
Family Need Inventory (CCFNI). She introduced the
CCFNI to 55 family members of hospitalized, critically ill
patients. The top 10 needs identified were similar to that
reported by Molter, with ‘to feel there is hope’ the most
important need identified in both studies. Although the
size of the samples in both studies was small, the findings
indicate that families of critically ill patients need to be
informed about the patient’s condition and assured that
their ill members receive the best care possible. In another
study, the CCFNI was administered to 52 family members
of critically ill patients during the first 18–24 h of hospi-
talization.12 The participants felt that, of the top 10 needs,
‘to be called at home about the patient’s condition’ was
the most important need followed by ‘to know the prog-
nosis’. The authors also found that only four of the top 10
needs were perceived as being met by the participants.
In 1991, Leske evaluated the construct validity of the
CCFNI using factor analysis.13 Her findings provided evi-
dence for the multidimensional conceptualization of the
CCFNI with five factors extracted. These factors include:
1. Needs for support including resources, support sys-
tems or support structures.
2. Needs for information which reflect the family’s needs
for realistic information about the critically ill member.
3. Needs for comfort that encompass personal comfort
needs.
4. Needs for proximity which refer to personal contact
and remaining near the critically ill relative.
5. Needs for assurance, that is, the family’s need to hope
for desired outcomes.
66
Using the multidimensional form of the CCFNI, other
researchers conducted a study to identify the needs of 45
family members of hospitalized, critically ill patients.9 The
finding of this study indicated that the most important
needs were related to assurance, proximity and informa-
tion. These needs were also ranked the highest by a larger
sample (n = 94) of family members of critically ill
patients.14 In the later study, needs for information and
proximity were not perceived as being met. Furthermore,
a review of eight studies using the CCFNI concluded that
the need for information was one of the top 10 needs
perceived by family members as important.15 In a
specific population of families of critically ill neurological
patients, the most important needs reported were related
to information and counselling,16 and assurance.17 Needs
for support and comfort were ranked the least in impor-
tance compared to information, proximity and assurance
by families of critically ill neurological patients in Hong
Kong.17
Studies that qualitatively analysed the experience of
family members of critically ill patients provide evidence
for the importance of needs for information and assur-
ance. In these studies, the most important themes emerg-
ing from family members’ experiences were being with
and seeing relatives,18 information seeking and tracking
relatives’ progress.19 These experiences might reflect that
families need to be certain about the status and progress of
relatives, which the families attempt to fulfill through
active information seeking and visual observation of their
relatives.
In summary, family members of critically ill patients
have specific and identifiable needs during hospitalization
of their critically ill relatives. The most important needs
are related to information about patients’ condition that
families expect to meet through health care providers or
by being with and seeing the patients. This information
provides families with certainty about the prognosis of
their relatives and the quality of care they receive.
METHODS
Design and sample
A descriptive cross-sectional design was used in this study.
The settings were CCUs of the four largest public hospi-
tals in the northern and middle areas of Jordan. The four
CCUs contained 6–8 beds that receive patients with a
variety of critical, life-threatening illnesses, and trauma
patients. Potential participants were family members who
MA Al-Hassan and IM Hweidi
came to visit their critically ill relatives in the identified
CCUs. The family members were:
• The partner, parent, adult child, adult grandchild or
adult sibling
• 18–70 years of age
• Able to read and understand Arabic
• Willing to complete the questionnaires within 18–72 h
of the patient’s admission to the CCU
Between 1 February and 30 May 2002, 240 packages
were distributed to eligible participants. One hundred
and sixty participants returned the packages, reflecting a
response rate of 66.6%. However, two packages included
incomplete data and were excluded from the study. The
remaining 158 comprised the study sample.
Procedure
Once permission to use the sociodemographic question-
naire and CCFNI was secured, a panel of four Masters-
prepared nurses and four lay people, who were competent
in Arabic and English languages, translated and back-
translated the questionnaires. Back-translation is a stan-
dard procedure for translating a research questionnaire
from English to other languages.20 Later, the question-
naires were introduced to six family members of hospital-
ized, critically ill patients to evaluate their clarity. Slight
rewording was made based on the panel’s and family
members’ suggestions.
The Jordan University of Science and Technology
research and ethical committee approved the study.
Permission to recruit participants was obtained from the
hospitals’ directors. Four Masters-prepared nurses
distributed the questionnaires to the study participants.
Prior to data collection, the primary investigator
explained the purpose of the study, data collection proce-
dure, and inclusion and exclusion criteria to the nurses.
The nurses were requested to introduce a package of the
questionnaires to each family member who came to visit
and met the inclusion criteria. The nurses distributed the
packages during the formal visiting hours.
The package included the CCFNI, sociodemographic
questionnaire, a letter to the participants that addressed
the significance and purpose of the study and a consent
form, which informed the visitors that their participation
was completely voluntary and their identification infor-
mation would be kept anonymous. The participants were
also advised to complete the questionnaires and leave the
package in a designated box near the nursing station.
Needs of families of critically ill patients
Instruments
The first questionnaire related to sociodemographic data
and consisted of eight items:
• The gender of the patient
• The gender of the family member
• The relationship of the family member to the patient
• The age of the family member
• The age of the patient
• The educational level of the family member
• Previous hospital experience
• The perceived health condition of the patient
The second instrument, the CCFNI, included 45 items
regarding family needs.8 These need statements were pre-
viously developed through a literature review and a survey
of graduate students.11 Family members responded to the
need statements by rating each one on a four-point
Likert-type scale in the following format:
1. Not important.
2. Slightly important.
3. Important.
4. Very important.
The psychometric properties of the CCFNI were tested
using a large sample size.13 A Cronbach alpha of 0.92 was
demonstrated. A principal components factor analysis
with varimax and oblimin rotations revealed five factors:
• Support (15 items)
• Comfort (six items)
• Information (eight items)
• Proximity (nine items)
• Assurance (seven items)
Internal consistency reliability of the factors were 0.88,
0.75, 0.78, 0 .71 and 0.81 for support, comfort, infor-
mation, proximity and assurance, respectively. In this
study, the CCFNI demonstrated an acceptable level of
internal consistency reliability (a = 0.76). However, the
CCFNI subscales showed low internal consistency reliabil-
ities: 0.61, 0.63, 0.62, 0.68 and 0.60 for information,
proximity, assurance, comfort and support, respectively.
RESULTS
Sample characteristics
The majority of the sample was male (63.9%) and young
adult (M = 36 years, SD = 12.38), and had attained high
school education or greater (72%). More than 70.9% of
the participants were sons or daughters, 15.2% were par-
ents and 13.9% were brothers or sisters of the hospital-
ized, critically ill patients. Only 35.5% perceived the
67
health conditions of their ill relatives as stable, whereas
38% and 26.5% evaluated the patient’s health condition as
serious or critical, respectively. Almost 64% of the par-
ticipants had pervious experience of hospitalization
of ill relatives. The hospitalized, critically ill patients
were mostly male (60%) and older adults (M = 44.8,
SD = 20.8).
Families’ needs
More than half of the sample perceived 41 needs as impor-
tant or very important. Only four need statements were
perceived as such by < 50% of the sample. Sixteen needs
were perceived as important or very important by > 80%
of this sample (Table 1). However, only five needs were
perceived as very important by > 80% of the sample.
These needs were ‘to receive information about the
patient once daily’, ‘to feel that the hospital personnel care
about the patient’, ‘to have the information given in
understandable terms’, ‘to have questions answered hon-
estly’, and ‘to know the prognosis’. Of these very impor-
tant needs, four were related to assurance and one was an
indicator of proximity. Also, seven of the top 16 needs
were related to assurance, five to proximity, three to
information and one was related to support. None of the
needs was related to comfort. Table 2 shows the means of
the CCFNI dimensions. The sample ranked needs for
assurance, proximity and information the highest, and
needs for support and comfort the lowest.
DISCUSSION
In this study, we attempted to identify perceived needs of
Jordanian families of hospitalized, critically ill patients.
The majority of Jordanian families perceived 16 needs as
important or very important. These needs were related to
assurance, proximity and information. The most impor-
tant needs as perceived by Jordanian families were rela-
tively similar to those identified by the western
population.8,9,11–14
Of the top five needs, four were related to assurance.
This finding might indicate that the major concern of
Jordanian families is the health condition of their critically
ill relative. They need to be sure about the prognosis and
quality of care received. Previous work indicated that
needs for assurance were the most important for families
of critically ill patients.8,17 Assurance is a strategy that aids
in alleviating stress and reducing uncertainty.13 It is con-
ceptualized as families hoping for desired outcomes,13 and
68 MA Al-Hassan and IM Hweidi

Table 1 Needs that were perceived as important and/or very important by ≥ 80% of the participants

Number Need statements Mean (SD) Perception of importance of

needs (%)
A B Total

1 To talk to the doctor every day 3.35 (0.66) 45.5 44.2 99.7
2 To feel that hospital personnel care about the patient 3.87 (0.43) 10.8 88.6 99.4
3 To receive information about the patient once a day 3.90 (0.37) 6.3 92.4 98.7
4 To have questions answered honestly 3.80 (0.43) 17.7 81.0 98.7
5 To receive explanations in terms that are understandable 3.83 (0.38) 12.0 85.4 98.1
6 To know the prognosis 3.79 (0.48) 17.7 80.4 98.1
7 To know specific facts concerning the patient’s condition 3.50 (0.56) 47.1 49.7 96.8
8 To feel there is hope 3.60 (0.67) 22.3 68.8 91.1
9 To know why things were done to the patient 3.70 (0.65) 43.9 45.5 90.4
10 To be assured that the best care possible is being given to the patient 3.50 (0.74) 25.3 63.3 88.3
11 To be told about transfer plans while they are being made 3.40 (0.79) 26.6 58.4 85.0
12 To have a specific person to call at the hospital when unable to visit 3.40 (0.76) 31.0 53.8 84.8
13 To visit at any time 3.34 (0.81) 30.6 52.4 83.5
14 To be called at home about changes in the patient’s condition 3.30 (0.74) 34.8 48.1 82.9
15 To have explanations of the environment before going into the critical 3.20 (0.84) 41.8 39.2 81.0
care unit for the first time
16 To see the patient frequently 3.40 (0.87) 19.7 60.5 80.2

A, important; B, very important; SD, standard deviation.

Table 2 Families members’ rank order of the Critical Care Family tive and tracking his/her progress are needed to alleviate
Need Inventory dimensions family members’ stress and uncertainty.13 It was reported
that family members of critically ill patients experienced
Area of needs Potential range Mean (SD) Rank information seeking behaviour to move out of the hover-
ing state, a sense of stress and uncertainty.19
Assurance 17–28 25.86 (1.9) 1 Needs for proximity or remaining near the critically ill
Information 8–32 25.57 (2.6) 2 relatives, physically and emotionally, have been described
Proximity 9–36 28.66 (2.7) 3 in previous research.8,11,12 Observing the relative’s body
Comfort 6–24 17.30 (3.8) 4 provides direct information about the progress of the rel-
Support 15–60 42.30 (5.3) 5 ative’s health condition.15 In addition, family members
need to be with their ill relatives to maintain the natural
SD, standard deviation. bond among them.
Although public hospitals in Jordan do not provide
meeting these needs might promote the families’ hope for waiting rooms and other comforting measures for
better expectations about the patient’s condition. patients’ visitors, needs for support and comfort were
Families of critically ill patients might need information ranked the lowest. In other cultures as well, families of
to be certain about the progress of the patient’s condition. critically ill patients ranked the needs for support and
Realistic information might help the families in making comfort the lowest.9,14,17,21 In the latter study, physicians,
sound decisions as to what to do next. The information nurses and relatives of critically ill patients scored fami-
might be obtained from health care providers or by being lies’ needs for information the highest with less impor-
with and seeing the patients. Information about the rela- tance attached to comfort and support needs. These
Needs of families of critically ill patients
studies, in combination with this study’s findings, suggest
that families of critically ill patients give less value to sup-
port and comfort needs, although comfort is considered a
substantive need throughout life22 and a desirable holistic
outcome that has been used as a standard to measure the
quality of nursing practice.23
These studies operationalized comfort as a unidimen-
sional construct using the CCFNI. This inventory focuses
on physical environmental needs of comfort only. Com-
fort, however, is a multidimensional construct that has
been defined as the state of having met basic human needs
for relief, ease and transcendence in four contexts of
experience including physical, environmental, psychos-
piritual and sociocultural.24
Relief indicates the experience of having a specific com-
fort need met, ease is a state of calm or contentment,
whereas transcendence refers to the state in which one can
rise above pain or problems.
The first context of comfort needs, physical comfort
needs, includes disruptions in physiologic mechanisms
that need correcting and maintaining of homeostasis. Psy-
chospiritual comfort needs refer to clients’ needs for
inspiration, motivation and being able to rise above dis-
comfort and problems. Environmental comfort needs
include needs for a quiet, peaceful, safe and comfortable
environment. Finally, sociocultural comfort needs refer to
clients’ needs for support, reassurance and caring that are
culturally sensitive. The social context of comfort was
described as including interpersonal, family and cultural
relationships, as well as financial and informational aspects
of social life.24
Watson described comfort as an external variable that
the nurse could control, and provision of a supportive and
protective mental, physical, sociocultural and spiritual
environment as a comforting activity.25 The same author
asserts that comforting measures should be related to the
habitual ways of the client’s culture, family life or social
class. Leinneger emphasizes that cultural understanding of
comfort is necessary for nurses to provide holistic quality
care, asserting that nurses must consider the meaning that
comfort has for a specific individual or family culture
group.26
It might be that the participants in most of the studies
reviewed scored comfort low because the CCFNI does
not reflect the multidimensional conceptualization of
comfort, particularly mental and social aspects that might
be considered by the families more important than a com-
forting waiting room. In brief, comfort is a multidimen-
69
sional construct and assessment of this construct should
include all aspects of comfort.
Consistent with other studies’ findings,13,14 a positive
relationship between comfort and support was found
(r = 0.31, P < 0.005) in the current study. Furthermore,
it was reported that support from church, families and
friends enhanced comfort.22 This relationship, and con-
ceptualization of different forms of support as aspects of
comfort, suggest a complex interaction among needs of
families of critically ill patients. Kolcaba holds that com-
fort is the result of meeting human basic needs.23 The same
author conceptualized comfort as a higher order con-
struct. Lower order constructs, hope and contentment,
were aspects of comfort.27 She maintained that education,
support, assurance and hope were all aspects of comfort
and an intervention intended to enhance one aspect of
comfort enhances other aspects.24 However, provision of
information was conceptualized as one dimension of social
support,28,29 and assurance was defined as families’ need to
hope for desired outcomes.13 Information is needed to
help families cope with encountered problems, make
sound decisions and go on with normal living. Fulfilling
this need might help individuals experience the transcen-
dence dimension of comfort. Particularly, it was demon-
strated that provision of information improved comfort.30
Being with the patients also helped individuals with the
interpersonal and social aspects of relationships. The ulti-
mate goal of the families is to experience mental, physical
and social comfort so meeting basic needs, including
information about patients’ status, being with or seeing
the patients and hoping for better outcomes are necessary
requirements for the families to achieve comfort. Based
on this argument, one can postulate that information,
proximity and assurance might be perceived as supportive
measures or needs that should be met through a support-
ing, culturally sensitive environment in order for the fam-
ilies to achieve comfort.
In the Jordanian culture, however, the family size is
large and characterized by strong ties among its members.
Adult members of the family might participate in the
members’ health care, seeking information or even mak-
ing personal decisions. Visiting and providing support to
families of sick patients is a social norm practised by the
families’ relatives and friends which might decrease their
perceptions of needs for support. Also, it might be that
Jordanian families are more concerned about the patients’
condition and the quality of care delivered than the avail-
ability of comfortable waiting rooms. The majority of
70
Jordanians are Moslems who believe that illness or well-
ness is God’s will and their faith is within God’s hands
only. They might use prayers and other religious practices
to help them cope with stressful situations and promote
their psychological comfort.
Limitations
This study is the first to describe the needs of Jordanian
families of hospitalized, critically ill patients. However,
the generalizability of the findings should be viewed with
caution. First, the sampling technique used to recruit the
participants did not ensure that the sample was represen-
tative of the total population. Second, there were no
demographic data for those family members who refused
to participate or failed to return the questionnaires.
Another limitation is related to low reliability of the
CCFNI subscales. This scale might lack sensitivity to elicit
needs of Jordanian families who might have different
beliefs and values compared to western populations. In
addition, the CCFNI measures the environmental aspect
of comfort and does not include other aspects (mental,
spiritual or social).
Nursing implications
and recommendations
Almost 92% of the needs statements were perceived as
important or very important by more than 50% of the
sample. This finding is alarming if these needs are not
being met. The health care system in Jordan should give
more attention to families of critically ill patients, partic-
ularly their psychological status. A holistic approach of
nursing management requires that nurses assess families’
needs using valid and reliable tools and develop interven-
tion strategies and counselling programmes to meet the
identified needs. Specifically, families’ need for informa-
tion about their relative’s condition and prognosis, the
delivery of information in understandable terms and
receiving honest and respectful care are critical needs that
require special attention. It would be worthwhile for
nurses to begin to adopt interventions to meet these spe-
cific needs first because it might be unrealistic for nurses
to deal with all aspects of families’ needs.
Nurses’ recognition of the families’ needs to receive
the information in understandable language should be an
essential element of any counselling or intervention pro-
gramme. Using simple and clear terms and respecting the
family members’ knowledge and concerns could foster
the family members’ understanding of the patient’s con-
MA Al-Hassan and IM Hweidi
dition and their confidence in the quality of care deliv-
ered. Providing updated information to the families of
critically ill patients, involving them in the patient’s care
and including them in the discharge planning are sug-
gested interventions that might decrease the families’
stress and increase their certainty of the patient’s
progress.
It might be valuable to replicate this study using reliable
and valid measures to assess the needs of families of crit-
ically ill patients and determine whether or not these
needs are being met, particularly a measure that addresses
all dimensions of comfort needs. Examining the interac-
tion among needs of families of critically ill patients
deserves nurse researchers’ attention. This examination
might reveal a theoretical base for intervention
approaches that promote the families’ coping ability. Fur-
ther research is also needed to examine the effects of the
families’ needs on their well-being, coping and their capa-
bility in providing support and care to ill members.
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