Intensive and Critical Care Nursing 43 (2017) 123–128

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Intensive and Critical Care Nursing

journal homepage: www.elsevier.com/iccn

Research article

The needs of the relatives in the adult intensive care unit: Cultural
adaptation and psychometric properties of the Chilean-Spanish
version of the Critical Care Family Needs Inventory
Noelia Rojas Silva a,∗ , Cristobal Padilla Fortunatti a,c , Yerko Molina Muñoz b ,
Macarena Amthauer Rojas c
a
School of Nursing, Pontificia Universidad Católica de Chile, Santiago, Chile
b
School of Psychology, Universidad Adolfo Ibáñez, Santiago, Chile
c
Unidad de Paciente Critico, Hospital Clinico UC CHRISTUS, Santiago, Chile

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: The admission of a patient to an intensive care unit is an extraordinary event for their
Received 19 May 2017 family. Although the Critical Care Family Needs Inventory is the most commonly used questionnaire for
Received in revised form 25 June 2017 understanding the needs of relatives of critically ill patients, no Spanish-language version is available.
Accepted 14 July 2017
The aim of this study was to culturally adapt and validate theCritical Care Family Needs Inventory in a
sample of Chilean relatives of intensive care patients.
Keywords:
Methods: The back-translated version of the inventory was culturally adapted following input from 12
Psychometrics
intensive care and family experts. Then, it was evaluated by 10 relatives of recently transferred ICU
Intensive care
Family
patients and pre-tested in 10 relatives of patients that were in the intensive care unit. Psychometric
Nursing properties were assessed through exploratory factor analysis and Cronbach’s ! in a sample of 251 relatives
Needs assessment of critically ill patients.
Results: The Chilean-Spanish version of the Critical Care Family Needs Inventoryhad minimal semantic
modifications and no items were deleted. A two factor solution explained the 31% of the total instrument
variance. Reliability of the scale was good (! = 0.93), as were both factors (! = 0.87; ! = 0.93).
Conclusion: The Chilean-Spanish version of theCritical Care Family Needs Inventory was found valid and
reliable for understanding the needs of relatives of patients in acute care settings.
© 2017 Elsevier Ltd. All rights reserved.

Implications for clinical practice

• Health professionals need validated questionnaires in order to perform reliable evaluations of latent variables in the ICU.
• The Chilean-Spanish version of the CCFNI possesses adequate psychometric properties for identifying the needs of the critical care
relatives.
• Knowing the needs of the ICU relatives is a unique opportunity for nurses to provide holistic care for both the patient and their
family.

Introduction

Admission to the Intensive Care Unit (ICU) is an event that sig-

∗ Corresponding author at: School of Nursing, Pontificia Universidad Católica de
Chile, Avda. Vicuña Mackenna 4860, Macul, 7820436 Santiago, Chile.
E-mail address: nprojas@uc.cl (N. Rojas Silva).
nificantly impacts the life of the patients and their family. This
uncertain and life-threatening situation alters the normal family
routine, it’s lived in an unfamiliar environment that is often unwel-
coming and involves a healthcare team that primarily focusses on
the medical treatment of the patient, leaving the family on the side-
lines. In this context, families suffer high levels of anxiety, stress and

http://dx.doi.org/10.1016/j.iccn.2017.07.006
0964-3397/© 2017 Elsevier Ltd. All rights reserved.
124 N. Rojas Silva et al. / Intensive and Critical Care Nursing 43 (2017) 123–128
depression that can last even after the patient is released (Cameron
et al., 2016; Haines et al., 2015).
One way to address this issue is to know the needs of the family
members and to what degree these needs have been met. Research
in the last decade has found that the most important needs of
family members of critical care patients are related to assurance
and information (Paul and Rattray, 2008; Verhaeghe et al., 2005).
Based on this, some interventions centered on the needs of patient
family members in the ICU have positively impacted in their sat-
isfaction and, even, decreased psychological impact (Chien et al.,
2006; Kynoch et al., 2016).
While there are a number of instruments existing to determi-
nate family needs in the ICU, the most commonly used is the Critical
Care Family Needs Inventory (CCFNI) (Olano and Vivar, 2012). This
instrument was created to allow patient family members to hierar-
chically classify a group of needs related to assurance, information,
support, comfort, and proximity (Leske, 1991). The CCFNI has been
validated in several languages and the original version is available
in English (Leske, 1991), French (Coutu-Wakulczyk and Chartier,
1990), Chinese (Chien et al., 2005), Farsi (Bandari et al., 2014), and
German (Bijttebier et al., 2000). Currently, only a short version
of CCFNI is available in Spanish-language (Gómez Martínez et al.,
2011).
Although family needs have been systematically evaluated with
the CCFNI (Al-Hassan and Hweidi, 2004; Chatzaki et al., 2012;
Prachar et al., 2010), there is currently no published research in
Spanish-speaking countries in Latin American. This point is of
particular importance, as cultural and geographic contexts could
become important factors in determining the importance of the
family needs and influence how these needs are categorized by the
family members (Al-Hassan and Hweidi, 2004; Chien et al., 2006;
Wang et al., 2004).
The objective of this study was to culturally adapt and validate a
Spanish-language version of the CCFNI in family members of critical
care patients at the ICU of a teaching hospital.
Methods
Design and participants
This study was carried out in a group of 251 family members of
patients hospitalised in the ICU of a teaching hospital in Santiago,
Chile. The inclusion criteria for family members were as follows: (1)
to be a direct family member, including non-blood relationships,
such as spouses and partners; (2) to be older than 18 years; (3)
to have at least an 8th-grade educational level; (4) have visited
the patient at least once time before the invitation; and (5) length
of stay in the ICU > 48 hrs. Individuals were invited to participate
during ICU visiting hours.
Instruments
The instruments used for data collection were as follows: (1)
Sociodemographic questionnaire of ICU relatives, and (2) the orig-
inal version of the CCFNI, in Spanish. The CCFNI consists in a list of
45 needs with Likert responses, distributed among five dimensions
(i.e. assurance, proximity, information, comfort, and support), and
one open-response item to express other needs (Molter, 1979). The
CCFNI has a reported reliability of ! = 0.92 for the general scale and
! = 0.61; 0.71; 0.78; 0.75; and 0.88 for the dimensions of assurance,
proximity, information, comfort, and support, respectively (Leske,
1991).
Translation and cultural adaptation process
The translation and back-translation of the original CCFNI were
performed by two independent bilingual nurses.. Then, the follow-
ing stages were adopted in order to culturally adapt and validate the
CCFNI: (1) content validity; (2) linguistic adaptation; and (3) con-
struct validity (Carretero-Dios and Pérez, 2007; Nunnally, 1987).
Content validity
The counter-translated CCFNI was evaluated by a multidis-
ciplinary group conformed by 12 experts which included two
intensive care specialists, three MSc nurses with ICU specialisation,
four clinical nurses with ICU specialisation, and three MSc nurses
with research experience and expertise in family-related subjects.
These experts were consulted regarding the congruency of each
evaluated item and the construct (i.e. needs of ICU family mem-
bers). The Lynn Index was calculated to establish the validity of the
content for each item (Lynn, 1986). The modifications proposed by
the experts were used to obtain an expert-adapted version of the
CCFNI.
Linguistic adaptation
The expert-adapted CCFNI was initially administered to a group
of 10 family members of patients, recently transferred outside the
ICU. Relatives evaluated the following aspects: language clarity,
concept clarity, wording, and adequate item comprehension. Once
their suggestions were incorporated, a third version of the CCFNI
in Spanish was created. For the pre-testing stage, 10 family mem-
bers of currently ICU patients completed the third Spanish version
of CCFNI and a semi-structured interview, about language clarity,
wording, and adequate item comprehension. In this final stage, the
instrument was not modified, thus producing the final Chilean-
Spanish version of the CCFNI.
Construct validity
In order to test the psychometric properties of Chilean-Spanish
version of the CCFNI, a sample size was determined according to
Brislin (1986) in which a minimum of five subjects were needed
for each item, translating into a minimum of 230 family members
of ICU patients. Exploratory factor analysis was used to extract the
ordinary least squares. Prior to factor analysis, items were assessed
for normality. Furthermore, Bartlett’s Test of Sphericity and the
Kayser Meyer Olkin index were used to determine if the correla-
tion matrix was appropriate for analyses. Afterwards, the number
of scaling factors was estimated by considering the following three
complementary criteria: (1) the Kaiser-Guttman Rule (i.e. latent
roots); (2) a Scree Plot (Hair et al., 2005; Martínez et al., 2006); and
(3) Horn’s parallel analysis (Buja and Eyuboglu, 1992; Horn, 1965;
Timmerman and Lorenzo-Seva, 2011).
Reliability was evaluated using Cronbach’s ! together with anal-
ysis of the discriminative capacity of the items by correlating each
reactant with the score for each instrument factor. For interpreta-
tion, values between 0.60 and 0.69 indicated acceptable reliability,
while 0.70–0.79 indicated high reliability and greater than 0.8 indi-
cated optimal reliability (Cervantes, 2005).
Data analysis
The descriptive statistics of the sociodemographic variables
were calculated using the statistical software SPSS for Windows
(v.22, 2012; SPSS Inc., Chicago, IL, USA). Factor analysis was car-
ried out using the statistical software R (R Development Core Team,
2008). Statistical significance for the hypothesis tests were defined
at p < 0.05.
Ethical considerations
Permission to carry out the CCFNI validation process was
obtained from the instrument’s author, Dr. Jane Leske.
 N. Rojas Silva et al. / Intensive and Critical Care Nursing 43 (2017) 123–128 125

Furthermore, this study was approved by the Ethical Commit- Table 1

Sociodemographic characteristics of participating family members.
tee of Pontificia Universidad Católica de Chile’s Nursing School (n◦
14–551). Characteristic Frequency Percentage

Gender
Results Male 88 35.1
Female 163 64.9
Cultural adaptation of the Chilean-Spanish version of CCFNI
Age
18–29 37 14.7
During the back translation process, the CCFNI had minimal 30–49 102 40.6
semantic changes related to the ambiguity of some items. Regard- 50–69 99 39.4
ing content validity, it was evaluated through expert judgments, 70+ 13 5.2
with only four of the 45 CCFNI items in the Spanish version hav- Educational Level
ing a Lynn Index < 0.8. These items were modified according to the Elementary 10 4.0
suggestions made by the experts. Similarly, all items were rated High School 97 38.6
as adequate. During qualitative analysis, some verb choices were Technical Institute 31 12.4
University 113 45.0
modified related to verb-linked elements. In this stage, no items
of the original CCFNI were deleted. In the linguistic adaptation and Religion
Catholic 189 75.3
pre-testing stages, family members ranked the items as 100% clear
Christian 23 9.2
and understandable and the instrument was not modified at all. No religion 34 13.5
Other 5 2.0
Sample group characteristics
Prior ICU Experience
Yes 148 59.0
The sample group contained a total of 251 family members of
No 102 41.0
ICU patients. The majority were females (65.0%); the average age
of participants was 47.2 years, and most of them had a university- Relationship with Patient
Parent 30 12.0
level education (45.0%). A significant percentage of family members Child 106 42.2
were adult children (42.2%) and over half had prior experience of a Partner 40 15.9
relative in the ICU (59%). The sociodemographic characteristics of Sibling 40 15.9
participating family members are summarized in Table 1. Other 35 13.9

ICU: Intensive care Unit.

Construct validity

Regarding the adequacy of exploratory factor analysis, 60% of
the items were verified as presenting an asymmetry coefficient less
than1 or greater than 1. Consequently, exploratory factor analysis
could not be applied to a Pearson’s correlation matrix, which was
therefore replaced by a polychoric correlation matrix (Muthen and
Kaplan, 1992). The statistics of the analysed matrix presented ade-
quate adjustments for carrying out factor analysis. Bartlett’s Test
of Sphericity obtained a value of 4648.7 (df = 990; p < 0.001), thus
supporting that the polychoric correlation matrix was not an iden-
tity matrix. Furthermore, the Kayser Meyer Olkin Index was 0.867,
which indicates that the obtained matrix was adequate for analyses
(Lloret-Segura et al., 2014).
Regarding the number of factors, three presented eigenvalues
greater than 1, whereas the Scree Plot demonstrated a signifi-
cant effect of the curve on two factors. Horn’s parallel analysis
demonstrated that the ideal quantity of factors would be two, since
eigenvalues were greater than those obtained from random sam-
ples, a result congruent with the Scree Plot (Fig. 1).
In line with the above analyses, a two-factor solution was
used; the eigenvalues of which were 11.68 and 2.37, thereby
explaining 31.22% of total instrument variance. The resulting factor
solution was rotated using the Direct Oblimin Method as orthogo-
nality between factors was not expected (the observed correlation
between factors was 0.44).

Fig. 1. Scree plot of the number of factors of the Chilean – Spanish version of CCFNI Number of Factors.
126 N. Rojas Silva et al. / Intensive and Critical Care Nursing 43 (2017) 123–128

Table 2
Factor loadings for each item under Factor 1 (Support) and Factor 2 (Communication).

ITEM (dimension) Factor 1 Factor 2

To know the expected treatment results for my relative. (A) 0.71

To have information on the Intensive Care Unit before arriving for the first time. (S) 0.45
To speak with the attending doctor every day. (I) 0.66
To have a specific person to call in the hospital when personal visits are not possible. (I) 0.44
To receive honest answers to questions. (A) 0.93
To be able to change the visiting hours under special circumstances. (P) 0.31
To talk about feelings related to what has happened. (S) 0.72
To have good food available in the hospital. (C) 0.53
To receive orientation on what to do at the bedside of my relative (S) 0.47
To visit my relative at any moment. (P) 0.37 0.34
To know which staff member can provide information (I) 0.31 0.41
To have friends close for support. (S) 0.56
To know why certain procedures are performed on my relative. (I) 0.77
To feel that there is hope. (A) 0.46
To know which hospital staff members are taking care of my relative. (I) 0.33 0.41
To know how my relative is being treated medically. (I) 0.57
To be sure that the best care possible is being given to my relative. (A) 0.4 0.54
To have a place to be alone in the hospital. (S) 0.8
To know exactly what is being done for my relative. (I) 0.68
To have comfortable furniture in the waiting room. (C) 0.52
To feel accepted by the hospital personnel. (C) 0.48 0.33
To have someone that can help with financial problems. (S) 0.52
To have a telephone close to the waiting room. (C) 0.75
To have visits with a priest, pastor, rabbi, or spiritual guide. (S) 0.69
To talk about the possible death of my relative. (S) 0.37
To have some company when visiting my relative in the Intensive Care Unit. (S) 0.75
To have someone concerned about my health. (S) 0.62
To be sure that it is okay to leave the hospital for a moment. (C) 0.46
To speak with the same nurse every day. (P) 0.47
To feel that it is alright to cry. (S) 0.71
To be informed about other people that could help me with problems. (S) 0.67
To have a bathroom close to the waiting room. (C) 0.52
To be alone at any moment. (S) 0.77
To have someone to talk with about family problems. (S) 0.79
To receive clear explanations. (A) 0.76
To have visiting hours that start on time. (P) 0.41 0.31
To be informed about the available religious services. (S) 0.75
To collaborate in the physical care of my relative. (I) 0.42 0.37
To know about transfer plans while they are being made. (P) 0.67
To be called at home if my relative has any change in condition. (P) 0.68
To receive information on my relative at least once a day. (P) 0.78
To feel that hospital personnel are concerned about my relative. (A) 0.78
To know that specific data on the prognosis of my relative. (A) 0.92
To see my relative frequently. (P) 0.81
To have a waiting room close to my relative. (P) 0.47

Only with factor loadings > 0.3.

P = proximity, A = assurance, S = support, I = information, C = comfort.

Regarding item distribution, factor 1 (denominated “support”)
grouped 27 items related mainly to needs included in the sup-
port and comfort dimensions of the CCFNI. In turn, factor 2
(denominated “communication”) grouped 18 items, primarily
corresponding to the dimensions of information and assurance
(Table 2).
Reliability was further assessed using Cronbach’s ! for the
factors and entire instrument. The general instrument presented
! = 0.93, whereas the “support” factor obtained ! = 0.87 and “com-
munication” ! = 0.93.
Discussion
The objective of the present study was to adapt and validate
a Spanish-language version of the CCFNI within Chilean popula-
tion in a teaching hospital. After expert evaluations, the items were
considered appropriate and, as such, deemed representative of the
needs presented by relatives of ICU patients. As with other val-
idation processes for the CCFNI, no items were deleted. This is
a testament to the international importance of family member
needs in the ICU (Bijttebier et al., 2000; Büyükçoban et al., 2015;
Chien et al., 2005). Nevertheless, the Turkish validation resulted in
the elimination of five items that did not meet the eight criteria
established by varimax rotation (Büyükçoban et al., 2015). Like-
wise, the French validation involved the addition of three items;
however, this modification was implemented by only one expert,
which could affect the validation process (Coutu-Wakulczyk and
Chartier, 1990). Related to this, literature recommends the inclu-
sion of least three experts for evaluating the pertinence of items
(Lynn, 1986).
The obtained two-factor solution differed from the original five-
factor structure presented by Leske (1991) and as confirmed by
posterior validation studies (Bandari et al., 2014; Bijttebier et al.,
2000; Chien et al., 2005). This should be considered in light of
the CCFNI created more than 25 years ago in the United States,
being representative of a different cultural and healthcare context
as compared to current patient- and family-centered approaches
(Mitchell et al., 2016). While the CCFNI was a pioneering instru-
ment for exploring the needs of family members in the ICU, the
theoretical foundation of this tool is rooted in evidence available
at the time (Molter, 1979). Furthermore, CCFNI items were cre-
ated on the basis of clinical experiences from a reduced number of
nursing professionals. This contrasts with studies that have found
inconsistences in how healthcare professionals identify and assign
 N. Rojas Silva et al. / Intensive and Critical Care Nursing 43 (2017) 123–128
importance to the needs of family members of ICU patients (Hinkle
et al., 2009; Maxwell et al., 2007).
From a methodological viewpoint, the reported validations of
the CCFNI have used factor analysis methods that could be affected
by previous steps. The original CCFNI was validated using principal
components analysis (Leske, 1991), similarly to other validations
(Bijttebier et al., 2000; Büyükçoban et al., 2015; Chien et al., 2005).
Regarding to this, the recent review by Lloret-Segura et al. (2014)
indicates that exploratory factor analysis and principal components
analysis have been frequently used interchangeably in instrument-
validation studies. However, if the purpose is to analyse the items
of a test based on factor structuring, then an exploratory factor
analysis is recommendable. This is because principal components
analysis, as a factor test, ignores measuring errors. This conse-
quently increases factor loading and the percentage of variance
explained by the factors, as well as possibly resulting in an over-
estimated dimensionality for the item set. Ultimately, this means
that interpretations based on solutions provided through principal
components analysis could be erroneous.
The name of the new factors considered the predominant con-
cepts within it. Thus, factor 1 was denominated “Support” and
included items that mostly reflected aspects associated with the
needs for company, family guidance by the healthcare team and
elements that might make the ICU environment more welcom-
ing. Therefore, providing support to families could contribute to
effective stress management and staying collected so as to sup-
port the patient (Kentish-Barnes et al., 2009). In turn, factor 2
was denominated “Communication” as this concept incorporates
more than the simple delivery of clinical information. The need
for information has been described as one of the most important
aspects for the family members of ICU patients (Padilla Fortunatti,
2014). Nevertheless, information is not always effectively deliv-
ered, and family comprehension is unassessed. One study in France
revealed that in 54% of cases, family members did not under-
stand information related to diagnosis, prognosis, or treatments
(Azoulay et al., 2001). In addition to routine communication with
physicians, other channels exist through which family members
can receive and exchange pertinent information, including the
use of pamphlets or structured meetings with the nursing team
(Garrouste-Orgeas et al., 2016). Although communication between
nurses and patient/family members frequently addresses biomed-
ical issues (Slatore et al., 2012), such instances also touch on family
needs related to the assurance dimension, such as “to receive hon-
est answers to questions” or “to feel that hospital personnel are
concerned about my relative” (Leske, 1991). Notably, these aspects
can be assessed in family members nonverbally by the healthcare
team. For Puggina et al. (2014), visiting hours can provide nonver-
bal signals of how family members feel and live the experience of
having a loved one in the ICU. This supports the idea that health-
care teams in highly complex units should develop the ability to
recognise nonverbal cues that could provide different inputs and
facilitate treatment implementation for both the patient and their
family.
Regarding reliability, the Chilean-Spanish version of the CCFNI
showed high levels that were similar to validations in Turkish
(! = 0.93), French (! = 0.90), and English (! = 0.92) (Büyükçoban
et al., 2015; Coutu-Wakulczyk and Chartier, 1990; Leske, 1991).
Strengths and limitations
The strengths of the present study include being the first to
culturally adapt and validate the CCFNI in Spanish and in Chile.
Similarly, the validation process involved a diverse group of experts
which allowed the establishment of a more holistic and complete
vision of the studied construct. Limitations include the fact that
127
participants were recruited in a private institution, which might
condition the socioeconomic and educational profiles of family
members. These factors could also influence how needs are pri-
oritised by family members in the ICU (Freitas et al., 2007).
Conclusion
The present study represents the first investigation directed to
culturally adapt validate the original CCFNI in Spanish-language in
Chile. The CCFNI adapted to the Chilean population is a valid and
reliable instrument for adequately assess the needs of family mem-
bers of ICU patients. Knowing the needs of ICU family members
represents an opportunity for healthcare teams to improve qual-
ity by gaining an integrated vision of patient care, which should
include and value the experiences lived by the family. It is expected
that availability of the validated CCFNI in the Chilean population
will constitute a valuable additional element for evaluating the
impact of family-centered care initiatives.
Funding source
This work was supported by the School of Nursing (Pontificia
Universidad Católica de Chile) through the “Integracion Docente –
Asistencial” program (IDA 2013) and by the Office of the Vice-Rector
for Research (Pontificia Universidad Católica de Chile) through the
Edition, Translation, or Revision of Articles Competition.
Acknowledgements
The authors thank all of the family members of critical-care
patients that participated in this investigation. The authors thank
Melissa A. Sutherland, from Boston College and 2017 Fulbright
Scholar, for her edits and suggestions.
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