Admission of a patient to an Intensive Care Unit (ICU) usually signifies that the patient’s physical health has suffered particular and possibly irreversible damage. The involvement of the patient’s relatives in this stressful procedure and the potential loss of a loved one naturally create psychological disruption, a burden that has significant implications for the family members’ mental health [1] [2] [3] [4]. Satisfaction from ICU hospitalization has been adequately studied for patients and various factors have been identified affecting their vulnerability to psychopathology symptoms, such as anxiety, depression, or post-traumatic stress disorder (PTSD), after ICU admission [5]. Analogous studies demonstrate the association between family psychological distress and satisfaction with ICU care [6].

In order to enlighten the relationship between psychopathology and satisfaction, one of the factors proposed in the literature is the concept of mental resilience, usually described as the subject’s ability to prosper despite the adversities he faces in life. The importance of resilience as a factor influencing psychopathology has been demonstrated by previous studies that suggested that the effect of stressful events on a subject’s psychopathology is strongly dependent on its resilience [7]. In particular, in the context of ICU, resilience has been associated with fewer symptoms of depression, anxiety, and acute stress, as well as larger satisfaction with the services provided for the patients’ family members [8]. Nevertheless, the factors that delimit and describe this relationship have not been sufficiently elucidated [9] [10].

More recently, the notion of self-compassion was also discussed as a possible resilience mechanism. Self-compassion is usually defined as the subject’s ability to behold a warm-hearted, caring, empathic and non-judgmental orientation towards the self during times of suffering and failure [11] [12]. As a notion, it originates from the Buddhism loving-kindness meditation, aiming to direct people to have compassion toward all living beings, including themselves [13]. All the published studies on self-compassion, use the self-compassion scale (SCS) [12] in order to measure this structure, since it is the only known available measure of self-compassion shown to be a valid and theoretically coherent measure of self-compassion [14]. In particular, self-compassion has been reported to be a potential buffer against psychopathology [15] [16] [17], functioning as a resilience mechanism and adaptive emotion regulation strategy [18]. Further, various practices have been found to enhance self-compassion in specific target groups such as health-care providers [19] [20] [21], parents of children with chronic conditions [22], or groups of persons suffering from specific diseases [23]. Although some current studies dispute the psychometric validity and theoretical consistency of SCS [24] [25], its reported effectiveness provides sufficient motivation for its further study.

The aim of the present study is to elucidate the relation between psychopathology, resilience, self-compassion, and satisfaction, aiming, in particular, to demonstrate the impact of self-compassion on the ability to address the ICU experience in patient attendants. Self-compassion is considered to be a resilience factor, a perspective that is highly adopted in the literature [26] [27] [28] [29], while, as commonly reported, both self-compassion and resilience are assumed to affect psychopathology [7] [30] [31] and satisfaction [8]. Under this perspective, an appropriate casual path model is formulated with which the mediation effect of resilience on self-compassion and psychopathology relationship, and the psychopathology mediation effect on the resilience and satisfaction relationship are additionally quantified.

In the current study, we studied 176 family members (71 men and 105 women, mean age 46.6 ± 11.6 years) of critically ill patients. These patients were admitted to the intensive care department with various medical and surgical conditions (176 patients, 120 men and 56 women, mean age 63.7 ± 17.3 years). One family member was interviewed for each of the 176 patients, 75 (42.6%) lived with the patient and 88 (50.0%) were grown children of the patients.

The four psychometric scales showed very good internal consistency with Cronbach’s alpha value ranged from 0.822 to 0.967 (Table 2). The resilience score of the patient’s family members was analogous to the reported score of the Greek validation of the scale on a sample of 244 healthy participants (70.7 vs 70.2, p_{diff = 0} = 0.378) [35]. On the other hand, self-compassion score was significantly higher than that reported in [36] on a sample of 1364 Greeks not being in a stressful situation (3.27 vs 2.97, p_{diff = 0} < 0.001), while the ICU satisfaction score

*Correlation is significant at the 0.05 level (2-tailed). **Correlation is significant at the 0.01 level (2-tailed). SCS: Self-Compassion Scale; CDR: Resilience; GSI: Global Severity Index, STF: Satisfaction.

was lower than a previous application in Greek hospital (76.5 vs 80.7, p_{diff = 0} = 0.005) [40].

General symptom index was negatively correlated with total satisfaction (r (176) = −0.194, p < 0.01), self-compassion (r(176) = −0.555, p < 0.01) and resilience (r(176) = −0.308, p < 0.01), while the latter two had a significant positive linear correlation (r(176) = 0.439, p < 0.01) confirming previous reports [41].

Patient’s age (PAGE), patient’s gender (PGND), type of relation (CHL) and age of the family member (AGE) did not have a statistically significant direct or interaction effect on the satisfaction and the three psychometric scales. In particular, patient’s age and gender, type of relation and age of the family member emerge to be factors with minor explaining ability (Table 3).

In contrast, gender of the respondent (GND) and living with the patient (STP) were found to significantly affect psychopathology and/or resilience. Specifically, women were found to have significantly larger psychopathology symptom index than men (0.81 ± 0.52 vs 0.60 ± 0.40, F(1, 166) = 10.826, p = 0.001), while respondents living with the patient (STP) were found to have a significantly larger score in psychopathology symptom index (0.87 ± 0.50 vs 0.61 ± 0.44, F(1, 166) = 10.247, p = 0.002), and lower resilience score (68.0 ± 14.9 vs 72.8 ± 13.2, F(1, 166) = 5.042, p = 0.026).

The aforementioned findings enlighten the mental state of the family member of the ICU patient. In particular, it is suggested that a path analysis model aiming to test the ability of self-compassion (SCS) and resilience (CDR) to explain psychopathology effect on satisfaction should also control for gender of the family member (GND) and living with the patient (STP) effects.

Following the preliminary analysis, the path model presented in Figure 1 was formulated and subsequently tested. The validity of the suggested mediations was assessed according to the Baron and Kenny (1986) approach. Using Pearson correlation coefficients, psychopathology, resilience and self-compassion were confirmed to be significantly associated with overall satisfaction, validating their role in the path model as independent variables or mediators. Further, they were significantly associated with each other, highlighting as legitimate the mediator role of resilience between self-compassion and satisfaction, as well as the mediator

(1) Error: 166, Total: 176, Corrected Total: 175. SCS: Self-Compassion Scale; CD-RISC: Connor-Davidson Mental Endurance Scale; GSI: Global Severity Index, STF: Satisfaction, GND: Gender.

role of psychopathology between self-compassion, resilience and satisfaction (Table 2).

The model was fitted using the maximum likelihood estimator and it converged after 88 iterations. The 2.6% of the self-compassion, 20.5% of the resilience, 37.6% of general symptom index and 8.7% of the total satisfaction variation was explained. The regression coefficients along with the indirect effects are presented in Table 4.

Relatives of ICU patients will inevitably experience or be exposed to suffering. Self-compassion represents a personal resource and supports self-care, ensuring that needs are not neglected particularly during times of suffering. This study aimed to contribute to the understanding of the nature of the relationships among self-compassion, resilience, psychopathology, and satisfaction for family members of ICU patients. Previous research indicated that resilience is an important factor that positively influences psychopathology and satisfaction [8]. This finding was also confirmed in our study since self-compassion and resilience were demonstrated to be related to enhanced resilience of the family members, milder psychopathology, and higher satisfaction with the treatment of their relative and their overall experience in the ICU environment.

Further, in the context of the relation between self-compassion and resilience, a new perspective is provided. A remarkable finding of this study is that the effect of resilience on psychopathology is fully explained by self-compassion, while self-compassion is additionally shown to have the ability to essentially eliminate the effect of both resilience and psychopathology on the satisfaction of the ICU experience for a patient’s family members. Self-compassion thus emerges as the key personality trait through which family members perceive the stressful experience of the ICU environment. In particular, a more balanced or mindful view of the family members’ condition is expected to make them feel less isolated, also improving their ability to cope with the emerging psychological disturbance.

Since both self-compassion and resilience have been proven to be modifiable, this finding suggests that an effective strategy for alleviating the psychological pain of relatives and increasing their satisfaction from the ICU experience would be to provide them with the means to strengthen these personality characteristics.

In the literature, various interventions to enhance resilience [42] [43] [44] or self-compassion [19] [45] have been shown to be effective. Furthermore, in the context of critical care, previous research has shown that peer supports groups assist family members of the patients to cope with depression and anxiety symptoms [46], as well as reduce psychological morbidity and increase social support for the patients [47]. The Vanstone et al. (2020) document contains multidirectional demonstrations of compassion between clinicians and family members, forging the type of human connections that may foster resilience [48].

It is implied that specialized trained ICU staff could facilitate peer support groups of family members aiming to enhance self-compassion and resilience. However, further research is required in order to adapt already successful practices or to explore new interventions targeted in this particular situation. In this context, our additional findings regarding the unfavorable psychopathological position of women and of those who live with the patient confirm previous studies [49] [50], and suggest that future interventions should be particularly targeted in these relative subgroups

Compassion is the beneficial response of an individual to the sufferings and difficulties of others. Self-compassion refers to feelings of concern an individual feel towards oneself. Both may serve as potential buffers in a hospital setting where caregivers attending to patients in critical condition experience emotional distress, which may lead to exhaustion [51]. The emotional strain inflicted on the family members of ICU patients requires ongoing care for themselves. Self-compassion is essential for the caregiver to maintain its long-term self-care and its resilience. The association of self-compassion with resilience was reflected in all the analyses performed in the current study.

The findings of the present study could provide an alternative approach to supporting patients’ family members during the particularly stressful experience they are going through. The constructs of self-compassion and resilience may help to revise our understanding of the way that family members of ICU patients perceive their experience and alleviate their mental burden.

Our study is a first step in developing the concept of “self-compassion and resilience” in family members of ICU patients and this is one of its major strengths. There were several limitations in our study. Self-report questionnaires have inherent limitations, including respondent recall bias and selection bias, since the family members who were the most affected by their loved one’s critical illness may have elected not to complete the questionnaire. Another limitation was that we did not evaluate family members’ resilience and self-compassion following the discharge of the patient from the ICU to determine if these symptoms improved as the critical illness resolved.

The hospitalization of a patient in the ICU is considered to be a factor that affects the self-compassion of patients’ relatives. Our results highlight the risk of psychologically-induced symptoms in ICU relatives and underline the need for a psychosocial support system for them. Self-compassion is shown to have the ability to essentially eliminate the effect of both resilience and psychopathology on the satisfaction of the ICU experience for a patient’s family members. Self-compassion thus emerges as the key personality trait through which family members perceive the stressful experience of the ICU environment.

The Ethics Committee of the University Hospital of Ioannina approved the study and informed consent was obtained from the patients’ family members.

The datasets during and/or analysed during the current study are available from the corresponding author upon reasonable request.

Conceptualization, G.P., P.S., M.G., A.P. and V.K.; methodology, G.P. P.S., M.G. and V.K.; investigation, P.S.; writing-original draft preparation, G.P., P.S., Z.K. and M.G.; writing-review and editing, G.P., P.S., M.G, Z.K. and V.K.; supervision, M.G., P.S. and V.K. All authors have read and agreed to the published version of the manuscript.

The authors declare that they have no competing interests.

Stamou, P., Gouva, M., Konstanti, Z., Papathanasiou, A., Koulouras, V. and Papathanakos, G. (2022) Psychological Factors Affecting the Family’s Satisfaction of Patients in an Intensive Care Unit: The Dominant Role of Self-Compassion and Resilience. Open Journal of Nursing, 12, 334-348. https://doi.org/10.4236/ojn.2022.125023

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