ORIGINAL CONTRIBUTION

Air Medical Transport: What the Family Wants to Know • Julia H. Fultz, RN, BSN; Jo Lynn McKee, RN, ADN; Franketta R. Zalaznik, RN, BSN;

Pamela S. Kidd, RN, PhD; University of Kentucky Hospital, Aeromedical Service, Lexington, Ky.

Introduction= The needs of family members of intensive care unit patients are well-documented, but there is little published about the specific needs of family members of air medical patients. Purpose= This study was devised to identify family member's information needs regarding air medical transport. Methods: Using a descriptive correlational design, 100 family members of air medical patients completed a 14-item Likert-format questionnaire. Each item ad- dressed an information need and asked how important the information was to the family member and how much of this information they received. Results: The information needs most frequently ranked as very important related to the patient's condition, the patient's admitting unit at the receiving hospital, and being able to see the patient prior to flight. Information most frequently re- ceived by the family related to the patient's condition. Conclusion: Flight crews need to be cognizant of families' needs and develop ways to improve communication with the family to meet those needs.

Key Words: Aeromedical, information needs

Introduction Air medical transportation provides the means to rapidly transport pa- tients to a medical facility capable of providing definitive care. The nature, inherent risks and expense associ- ated with this service necessitate re- serving air medical transport for the potentially critically ill or injured pa- tient. As a result, patients transported by air frequently have life-threatening conditions that require admission to an intensive care setting. It is well- documented that any sudden or un- expected hospitalization in an inten- sive care unit for an illness or injury may create a crisis situation for the patient and family. 1-4

The needs and concerns of fami- lies in critical care units have been studied for more than 15 years. In a review of this literature, the family's information needs have consistently

been identified as one of the most important.2,3, 5-7 Because the pa- tients in intensive care settings and air medical transport may be both physiologically unstable, similarities may be drawn between the informa- tion needs of these families.

Several components contribute to the unique information needs these families may have, such as their complete separation from the patient and caregivers, the stress of having to travel to an unfamiliar city for an unknown length of time, and the na- ture of the flight and the risks in- volved. Molter, Leske and Simpson recognized the need for identifica- tion of needs unique to special care units, and an air medical helicopter can be categorized as a special care unit.2,3, 8 Yet, there is no information regarding the specific needs of fami- lies of air medically transported pa-

tients. The needs and concerns in- herent to the air medical experience must be identified as an initial step in an effort to meet these needs.

Involvement in an unexpected in- jury or illness event with unpre- dictable health outcomes creates psychologic stress for the family. Information about the air medical transport experience may enhance the family's ability to problem solve and decrease their perceived stress by supporting their coping strate- gies. Families that manage this stress successfully may be able to provide bet ter support to the pa- tient, thus promoting the transition through the s tages of recovery. Urban states the family can provide the normal stimuli, support, and comfort for the patient and can help the feelings of social isolation many intensive care patients experience. 4 Rasie suggests a role for the family in helping the pat ient deal with fears about his illness and surround- ings and in orienting the patient to reality. 9

The goal of this s tudy was to identify the family members' needs for information concerning the air medical transport of an ill or injured person in their family. Specific aims included identification of informa- tion needs pe rce ived by family members specific to the flight expe- rience and examination of the de- gree to which family members per- ceived their needs for information were met.

Address correspondence to: Julia H. Fultz, RN, University of Kentucky Hospital, Aeromedical Service, 800 Rose St., HA038, Lexington, KY 40536-0084.

Air Medical Journal * November/December 1993 431

Methods Existing questionnaires that exam- ine family needs frequently address areas unrelated to the air medical transport experience, so the investi- gators developed a questionnaire specifically to address information needs pertinent to air medical trans- port. An assumption of this study was that once such needs are clari- fied, interventions can be imple- mented and evaluated for their ef- fectiveness.

A descriptive correlational design was used. The convenience sample consis ted of a family member of each of 100 patients who were flown by helicopter from either a scene or a refer r ing hospi tal to a Level I trauma center. The trauma center serves a largely rural region with wide variations in terrain and so- c ioeconomic status. Eligible pa- tients were defined as those flown by the air medical service of the Level I trauma center admitted to one of the intensive care units for more than 24 hours. A family mem- b e r was def ined as 18 yea r s or older, related to the patient by birth or marriage, who visited the patient in the intensive care unit. Family m e m b e r s were en te red into the study as they were accessible to the investigators, in a non-consecutive manner.

Once the study was approved by the hospital's Institutional Review Board, the families of eligible pa- tients were contacted in the waiting room or at the patient 's beds ide within 72 hours following the pa- tient's flight. If the family member agreed to participate, informed con- sent for the study was obtained. If more than one family member was present, the option to participate was given to a spouse or parent first. Informed consent was also ob- tained from patients to review med- ical and flight records unless situa- tions of critical illness precluded doing so. Information obtained from these records pertained to transport times, patient acuity, admitting diag- nosis and insurance status. Data col-

lection occurred over a nine-month period.

The study's Flight Information Questionnaire (FIQ) is a 13-item Likert-format questionnaire with two scaled responses. Each question ad- dressed an information need. On scale A, the family member rated each need according to perceived importance (1 = "not important" to 5 = "very important"). On scale B, the same needs were then rated accord- ing to the family member's percep- tion of how well each one was met (1 = "not met" to 3 = "completely met"). The FIQ concluded with an open-ended question for the respon- dent to provide additional informa- tion.

On scale A, the greater speci- ficity provided by answering on a 1 to 5 scale furnished more informa- tion about the issues about which participants felt strongly. Scale B addressed whether the information was addressed or not. The partial category on scale B (2 = "partially met") indicated the family member perceived they were given some in- formation but not enough. Greater specificity than this on scale B was of no benefit. Scale A applies to the families' general flight information needs. Scale B can provide informa- tion regarding the level of family and caregiver interaction. Once standards of care are developed, scale B can provide a means to col- lect quality assurance data.

The FIQ was reviewed for con- tent validity by nurses, paramedics, emergency medical technicians and physicians who had been exposed to air medical transport, and it was piloted with non-health care per- sonnel to assess ease of comprehen- sion. The FIQ was written on an eighth-grade reading level accord- ing to Frye's readability scale. 1°

After consent was obtained, de- mographic data was elicited for sta- tistical analysis of relationships with information needs. Family members were then given the FIQ to com- plete on their own. It was stressed that only the consen t ing adul t

should complete the questionnaire. Those who reques ted help were read the ques t ionna i re by a co- investigator or research assistant, who marked the se lec ted re- sponses. Questionnaires that were left with the family member were picked up within 24 hours. Of the 105 family members constituting the sample, two family members e lec ted not to part icipate in the study, and three ques t ionnai res could not be analyzed due to miss- ing data.

Results Sample Characteristics The majority of family members in- volved in the s tudy were female (73%). Family m e m b e r s ' ages ranged from 18 to 75 with most being between 36 and 45 years of age (39%). Most were spouses (34%) or parents (28%) and had at least a high school educa t ion (82%). Baptist (48%) was the most common religious affiliation. Drive time to the hospital for family m e m b e r s ranged from 20 minutes to three hours.

The most frequent patient diag- noses were myocardial infarction (32%), head injury (21%) and multi- ple trauma (20%). Sixty eight per- cent of the patients had Glasgow Coma Scales greater than 9; three percent were children and did not rece ive a Glasgow Coma Scale score.

Descriptive Findings Six information needs were rated as very important by at least 75% of family members (Table 1). Each item of the FIQ was considered very important by at least 35% of the fam- ily members.

The last question on the FIQ was an open-ended question: Is there anything else that you wanted to know? The responses were largely comments explaining an answer they had given. Two r e s p o n s e s were questions addressing how well the helicopter was equipped to care for the patient.

432 Air Medical Journal ° November/December 1993

The majority of family members perceived that insufficient informa- tion was given to them concerning how the patient did during flight, the safety of air transport, who was taking care of the patient during transport and directions to the re- ceiving hospital. These four items on the questionnaire were ranked as very important by 50% or more of the family members but received a low rating (<50%) on how well the information was provided (Table 1). Family members indicated that in- formation was provided by one or more of the following people; physi- cians (44%), referring nurse (23%), flight nurse (17%), flight paramedic (15%), another family member (6%), and state police, emergency med- ical personnel and friends (all <4%).

Psychometric Analysis Both scales were assessed for relia- bility and consistency among items using Cronbach's alpha coefficient. Scale A had a coefficient of 0.78 and scale B had a coefficient of 0.73.

The normal range for Cronbach's alpha is 0.00 to 1.00. The higher the value, the greater the ability of the items to measure what they are in- t ended to measure (information needs and how well those needs were met). An alpha coefficient of 0.70 or higher is considered satis- factory. 11

A factor analysis was also done on both scales to assess the reliabil- ity of the FIQ. This analysis was per- formed to see the similarity between items and to determine if any items could be discarded due to redun- dancy or lack of homogeneity. After analyzing the results, all of the items were determined to contribute to the reliability of the questionnaire, and no items were eliminated. Scale A correlated significantly with scale B (r = 0.80, p <.05), meaning the in- formation needs most frequently considered important were most fre- quently met.

Corre la t ions b e t w e e n scale scores, demographic information and the flight data revealed the fol-

lowing correlations (p <.05): Age was inversely related to perceived information needs; the longer the flight, the greater the perceived in- formation need; and the lower the Glasgow Coma Scale, the less infor- mation the family member felt was provided. Females had greater in- formation needs as compared with males based on t- test analys is (t (0,98) = 2.37, p = 0.02). There were no statistically significant rela- tionships between diagnosis, reli- gion, family-patient relationship and education with scale A or scale B scores. Details of the psychometric analysis are available on request.

Limitations The convenience nature of the sam- ple limits the ability to generalize the study's findings. In addition, there are no published studies iden- tifying family members ' needs for information related to air transport. This study should provide a basis for future research involving ran- domized, larger sample sizes.

Air Medical Journal • November/December 1993 433

The literature reveals inconsis- tencies over the correct number of subjects needed in relation to the number of questions for an accurate factor analysis. Sources cite a ratio of three subjects for each question as well as a ratio of 10 subjects for each question.12,13 In this study, seven subjects per quest ion was used. With ratios less than three, the influence of relationships based on random patterns within the data becomes more pronounced. 12

Almost 20% of the population of the United States has reading skills below the fifth-grade level, and 18% of the family members who partici- pated in the study reported grade school as the highest level of educa- tion completed. 14 The questionnaire was read to those requesting assis- tance and those not able to under- stand it to minimize error related to reading ability. Since completion of this study, the FIQ has been revised to a fifth-grade reading level using Frye's readability scale.10

The investigators recognized the potential for someone other than the consenting adult to have input on the questionnaire. This possibility was minimized by emphasizing to those filling out the questionnaire that it was necessary that only the adult consenting to participate in the study should answer the questionnaire. For the remaining participants, the research assistant was present to as- sist the family member in reading and understanding the questionnaire or to respond to questions. This presence deterred collaboration.

Six ques t ions on the demo- graphic data collection sheets had a selection of "other" as one of the an- swer choices. Some subjects se- lected "other" without explanation. Meaningful correlations may have been overlooked due to not asking for greater clarification when some- one selected this response.

Discussion The study results identified a num- ber of information needs that are considered very important by family

members of air medical patients. Improving communication with fam- ily members by all involved medical personnel will help meet these infor- mation needs. Mechanisms to im- prove communication with family members may include speaking to the family prior to flight; visiting with the family following the flight; edu- cating flight crew, referring, and re- ceiving personnel on the findings of this study; and developing written material for family members on what an air medical transport entails.

Only 24% of the family members in this study perceived any of the in- formation they obtained as coming from one or both of the medical crew (a fl ight nurse and para- medic). Thus, the authors recom- mend that flight personnel speak with family members prior to the flight to give them important infor- mation. It is recognized that time is frequently limited when a patient re- quires rapid transport to a facility capable of providing definitive care, so the investigators feel considera- tion should be given to meet ing family information needs while still meeting the frequent need for rapid patient transport.

The flight crew should also con- sider a follow-up visit with the fam- ily to provide information on the flight. How the patient fared during the flight was deemed very impor- tant information by 79% of the fam- ily members. Yet, only 21% felt this need was met by the flight service involved in this study.

Education of referring and re- ceiving pe r sonne l th rough in- service training regarding family in- formation needs will assist in dis- seminating the information family members feel they need. The study resu l t s can also be inc luded in flight-crew orientation programs.

Due to the crisis nature of critical illness, families may not compre- hend and process all of the informa- tion they receive. Air medical pro- grams may want to consider pre- paring written material for the fami- lies, as written material is an appro-

priate method of reinforcing and clarifying information and can be read and reviewed when the person feels able to do so. 5,15,16 Written in- formation may include directions to the hospital, information about the flight service, the safety of flying and the visitation policies of the re- ceiving facility.

There is a lack of research exam- ining the effectiveness of interven- t ions des igned to mee t family needs. Possible areas for future re- search include: 1) an evaluation of the effectiveness of interventions aimed at meeting family members' information needs regarding the flight experience; 2) evaluation of the therapeutic value of a follow-up visit with the family members from the flight crew; and 3) an evaluation of the family members ' perceived level of stress associated with air transport and the effectiveness of in- terventions to decrease their stress.

Patients remain the first priority in rendering care. However, it is also appropriate to consider the family in the care plan as patients are family members. The family can greatly influence the patient's recov- ery and adaptation and must be in- cluded when striving for optimal care. Pre-flight information and post-flight c losure may help the family member in understanding and coping with this experience. If supplying adequate information to the family enhances their ability to provide support to the patient, the ultimate goal of providing optimal care will be maximized.

Conclusion Information needs identified by fam- ily members as being very impor- tant include what was wrong with patient, why the patient had to be flown and where the patient would be on arrival at the receiving hospi- tal. Seeing the patient before he or she was put on the he l icopter , knowing how the patient fared dur- ing flight and knowing who was tak- ing care of the patient in flight were also considered important needs by

434 Air Medical Journal • November/December 1993

75% or more of the participants. The majority of family members per- ceived a lack of information given to them concerning how the patient did during flight, the safety of air transport, who was taking care of the patient and directions to the re- ceiving hospital. Flight crews need to be cognizant of family informa- tion needs and a t t empt to mee t these needs as the families' advo- cate. •

Acknowledgement: Grant support for this study was provided by the Foundation for Aeromedical Research.

References 1. Caine RM: Families in crisis: Making the

critical difference. Focus Crit Care 1989; 16(3):184-189.

2. Leske JS: Needs of relatives of critically ill patients: A follow-up. Heart Lung 1986; 15 (2) :189-193.

3. Molter NC: Needs of relatives of critically ill patients: A descriptive study. Heart Lung 1979; 8 (2) :332-339.

4. Urban N: Responses to the environment. In: AACN's Clinical Reference for Critical- Care Nursing. 2nd ed., Kinney MR, Packa DR, Dunbar SB (eds). NewYork, McGraw- Hill, 1988, pp 97-112.

5. Hickey M: What are the needs of families of critically ill patients? A review of the lit- erature since 1976. Heart Lung 1990; 19 (4) :401-415.

6. Spatt L, Ganas E, Hying S, Kirsch ER, Koch M: Information needs of families of intensive care unit patients. QRB 1986; 12:16-21.

7. Daley L: The perceived immediate needs of families with relat ives in the in- tensive care setting. Heart Lung 1984; 13 (3) :231-237.

8. Simpson T: Needs and concerns of fami- lies of critically ill adults. Focus Crit Care

1989;16:388-397. 9. Rasie SM: Meeting families' needs helps

you meet ICU patients' needs. Nurs'80 1980; 10:32-35.

10. Frye E: A readability formula that saves fime.J of Reading 1968; 2:513-516, 575-578.

11. Polit DF, Hungler BP: Nursing Re- search Principles and Methods. 4th ed., Philadelphia, JB Lippincott Co., 1991, p 370.

12. Kiine P: Handbook of Test Construction: Introduction to Psychometric Design. New York, Methuen Press, 1986, p 188.

13. Nunnelly J: Psychometric Theory. New York, McGraw Hill, 1978.

14. Stephens ST: Patient education materials: Are they readable? Oncol Nurs Forum 1992; 19 (1) :83-85.

15. Bozett FW, Gibons R: The nursing man- agement of families in the critical care set- ting. Crit Care Update Feb. 1983; 22-27.

16. Belcher AE: Teaching and learning. In: AACN's Clinical Reference for Critical- Care Nursing. 2nd ed. Kinney MR, Packa DR, Dunbar SB (eds). New York, McGraw-Hill, 1988, pp 463-476.

Air Medical Journal • November/December 1993 435