A Mixed-Methods Feasibility Study: Eliciting ICU Experiences and Measuring Outcomes of Family Caregivers of Patients Who Have Undergone Hematopoietic Stem Cell Transplantation.

The impact of an intensive care unit (ICU) admission on family caregivers of patients who have undergone hematopoietic stem cell transplantation (HSCT) has not been well described. Aims of this study were to determine the feasibility of conducting research with family caregivers of HSCT patients during an ICU admission and generate preliminary data about their experiences and engagement in care. Using a mixed-methods, repeated measures design, we collected data from family caregivers after 48 hr in the ICU (T1) and at 48 hr after transferring out of ICU (T2). Enrolling HSCT caregivers in research while in the ICU was feasible (10/13 consented; 9/10 completed data collection at T1); however, data collection at T2 was not possible for most caregivers. Caregiver distress levels were high, and engagement in care was moderate. The three themes that emerged from interviews (n = 5) highlighted that although HSCT family caregivers faced many challenges and received limited support during their ICU experience, they were able to access their own personal resources and demonstrated resilience.

A Qualitative Analysis of Factors Influencing Critical Care Trial Enrollment Among Surrogates.

BACKGROUND: We sought to identify factors that influence surrogate decision makers' decisions to enroll patients into a critical care randomized controlled trial. METHODS: We conducted a qualitative study embedded within a randomized controlled trial testing the effect of a behavioral nudge intervention for surrogate decision makers on enrollment rate in a sham ventilatory weaning trial among patients with acute respiratory failure. Participants were adult surrogate decision makers of patients receiving mechanical ventilation for acute respiratory failure. The study was conducted in 10 ICUs across 2 urban hospitals within an academic medical center in Philadelphia, Pennsylvanaia, United States. Immediately following their trial enrollment decision, surrogate decision makers were asked to enter free-text responses about the factors that influenced their decision. Responses were analyzed using content analysis. RESULTS: Of the 90 (49%) participants who provided free-text responses, the mean age was 54.9 years (SD 14.3), 69 (79%) were Caucasian, and 48 (53%) were the spouse of the eligible patient. We identified 5 themes influencing enrollment decisions: (i) trial characteristics, (ii) patient clinical condition, (iii) decision making processes, (iv) altruism, and (v) enrollment attempt. Among surrogates who enrolled the patient in the trial (n = 40), the most commonly cited factors were helping future patients (n = 24, 60%) and following the patient's wishes (n = 11, 28%). In contrast, those who declined enrollment (n = 50) most commonly reported that the patient was too sick (n = 27, 54%) and that they feared complicating the patient's condition (n = 11, 22%). CONCLUSIONS: Surrogates who enroll patients into trials most often cite altruistic motivations, while those who decline enrollment are most often concerned with the severity of the patients' condition.

National Estimates of Workplace Telehealth Use Among Emergency Nurses and All Registered Nurses in the United States.

INTRODUCTION: The goal of this research was to quantify the baseline status of prepandemic workplace emergency nursing telehealth as a key consideration for ongoing telehealth growth and sustainable emergency nursing care model planning. The purpose of this research was to: (1) generate national estimates of prepandemic workplace telehealth use among emergency and other inpatient hospital nurses and (2) map the geographic distribution of prepandemic workplace emergency nurse telehealth use by state of nurse residence. METHODS: We generated national estimates using data from the 2018 National Sample Survey of Registered Nurses. Data were analyzed using jack-knife estimation procedures coherent with the complex sampling design selected as representative of the population and requiring analysis with survey weights. RESULTS: Weighted estimates of the 161 865 emergency nurses, compared with 1 191 287 other inpatient nurses revealed more reported telehealth in the workplace setting (49% vs 34%) and individual clinical practice telehealth use (36% vs 15%) among emergency nurses. The geographic distribution of individual clinical practice emergency nurse telehealth use indicates greatest adoption per 10 000 state residents in Maine, Alaska, and Missouri with more states in the Midwest demonstrating emergency nurse adoption of telehealth into clinical practice per population than other regions in the United States. DISCUSSION: By quantifying prepandemic national telehealth use, the results provide corroborating evidence to the potential long-term adoptability and sustainability of telenursing in the emergency nursing specialty. The results also implicate the need to proactively define emergency nursing telehealth care model standards of practice, nurse competencies, and reimbursement.

Systematic review of family engagement interventions in neonatal, paediatric, and adult ICUs.

AIMS AND OBJECTIVES: The purpose of this systematic review was to evaluate interventions that have been used to engage families in direct care activities (active family engagement) in adult, paediatric, and neonatal intensive care unit (ICU) settings. BACKGROUND: Family engagement is universally advocated across ICU populations and practice settings; however, appraisal of the active family engagement intervention literature remains limited. SEARCH STRATEGY: Ovid Medline, PsycArticles & PsycInfo, Scopus, and CINAHL were searched for family interventions that involved direct care of the patient to enhance the psychological, physical, or emotional well-being of the patient or family in neonatal, paediatric, or adult ICUs. INCLUSION/EXCLUSION CRITERIA: Studies were included if an active family engagement intervention was evaluated. Studies were excluded if they were not published in English or reported non-interventional research. RESULTS: A total of 6210 abstracts were screened and 19 studies were included. Most studies were of low to moderate quality and were conducted in neonatal ICUs within the United States. Intervention dosage and frequency varied widely across studies. The interventions focused on developmental care (neonatal ICU) and involved families in basic patient care. Family member outcomes measured included satisfaction, stress, family-centred care, confidence, anxiety, and depression. Most studies found improvements in one or more outcomes. CONCLUSIONS: There is a paucity of literature about active family engagement interventions, especially in adult and paediatric populations. The optimal dosage and frequency of family engagement interventions remains unknown. Our systematic review found that data are limited on the relationship between family engagement and patient outcomes, and provides a timely appraisal to guide future research. RELEVANCE TO CLINICAL PRACTICE: Further research on the efficacy of family engagement interventions is warranted. The translation of active family engagement interventions into clinical practice should also be supported.

"Sedation is tricky": A qualitative content analysis of nurses' perceptions of sedation administration in mechanically ventilated intensive care unit patients.

INTRODUCTION: Critical care nurses are responsible for administering sedative medications to mechanically ventilated patients. With significant advancements in the understanding of the impact of sedative exposure on physiological and psychological outcomes of ventilated patients, updated practice guidelines for assessment and management of pain, agitation, and delirium in the intensive care unit were released in 2013. The primary aim of this qualitative study was to identify and describe themes derived from critical care nurses' comments regarding sedation administration practices with mechanically ventilated patients. METHODS: This is a qualitative content analysis of secondary text data captured through a national electronic survey of members of the American Association of Critical-Care Nurses. A subsample (n = 67) of nurses responded to a single, open-ended item at the end of a survey that evaluated nurses' perceptions of current sedation administration practices. FINDINGS: Multiple factors guided sedation administration practices, including individual patient needs, nurses' synthesis of clinical evidence, application of best practices, and various personal and professional practice perspectives. Our results also indicated nurses desire additional resources to improve their sedation administration practices including more training, better communication tools, and adequate staffing. CONCLUSIONS: Critical care nurses endorse recommendations to minimise sedation administration when possible, but a variety of factors, including personal perspectives, impact sedation administration in the intensive care unit and need to be considered. Critical care nurses continue to encounter numerous challenges when assessing and managing sedation of mechanically ventilated patients.

Delirium in the US: Results from 2023 cross-sectional World Delirium Awareness Day prevalence study.

IMPORTANCE: Delirium is an acute brain dysfunction associated with an increased risk of mortality and future dementia. OBJECTIVES: To describe the prevalence of clinically documented delirium in the United States on World Delirium Awareness Day 2023. DESIGN: Sub-analysis of a prospective, cross-sectional, online, international survey. SETTING: All healthcare settings were eligible with the exception of operating rooms and outpatient clinics. PARTICIPANTS: Healthcare clinicians, administrators, and researchers completed the survey. MAIN OUTCOME AND MEASURE: Prevalence of clinically documented delirium at 8:00 a.m. and 8:00 p.m. on March 15, 2023. Secondary outcomes were related to healthcare delivery. Descriptive statistics are reported. Differences between unit types (non-ICU vs ICU) were examined for all outcomes. RESULTS: Ninety-one hospital units reported on 1,318/1,213 patients. The prevalence of clinically documented delirium was 16.4% (n=216/1,318) at 8:00 a.m., 17.9% (n=217/1,213) at 8:00 p.m. (p= 0.316) and significantly differed between age groups, reported discipline, unit, and hospital types. Significant differences were identified between non-ICU and ICU settings in the use of delirium-related protocols, non-pharmacologic and pharmacologic management, educational processes, and barriers to evidence-based delirium care. CONCLUSION: To our knowledge, this is the first epidemiologic survey of clinically documented delirium across two time points in the U.S.. Delirium remains a significant burden and challenge for healthcare systems. The high percentage of units using delirium management protocols suggests administrator and clinician awareness of evidence-based strategies for its detection and mitigation. We provide recommendations for future studies and quality improvement projects to improve clinical recognition and management of delirium.

Nurse-led heart failure educational interventions for patient and informal caregiver dyads: An integrative review.

BACKGROUND: Heart failure is a major health problem with significant economic burden in the United States. Educating heart failure dyads (heart failure patient and informal caregiver) is a relatively new domain and is being proposed by providers, policy makers, and third-party payors. Nurse-led dyad education can improve quality of life and reduce hospital admissions in the heart failure population. OBJECTIVES: This integrative literature review focused on evaluating design, delivery content, and outcomes of nurse-led dyadic educational interventions. METHODS: PubMed, CINAHL, Cochrane, and Google Scholar databases (1999 -2022) were searched for quantitative and qualitative studies that included these search terms: heart failure, dyads, nonmedical caregivers, caregivers, randomized controlled trials, nurse-led education, education. RESULTS: The search yielded 92 articles. The results included seven randomized controlled trials and one pilot study conducted from 2005 to 2017. Sample sizes ranged from 20 to 155 dyads. Dyads who received education interventions had positive outcomes. Face-to-face coaching provided stronger outcomes. Interventions varied in length from baseline to three months, with post-intervention follow-ups from one to 12 months. CONCLUSIONS: A paucity of studies of nurse-led heart failure dyadic educational interventions have been reported in the literature. To advance the science and decrease heart failure readmissions, greater efforts to study and incorporate education and support for heart failure dyads is needed, along with assessment of both patient and caregiver outcomes.

Efficacy of a bioburden reduction intervention on mobile phones of critical care nurses.

BACKGROUND: Current literature identifies mobile phones of staff as potential vectors for hospital-acquired infection. METHODS: A pre-post, quasi-experimental study was conducted in a 20 bed intensive care unit (ICU). Surface bioburden of personal and shared mobile phones was estimated with a luminometer, expressed in Relative Light Units (RLU). Effects of a simple sanitizing wipe-based disinfection routine were measured at baseline, and at 1, 3, 6, and 12 months after implementation of the disinfection routine. RESULTS: Personal mobile phones and shared phones of 30 on-shift ICU nurses were analyzed at each collection. RLUs for personal phones decreased from baseline to 12 months post-intervention (Geometric mean 497.1 vs 63.36 RLU; adj P < .001), while shared unit phones also demonstrated a decrease from baseline to 12 months post-intervention (Geometric mean 417.4 vs 45.90 RLU; adj P < .001). DISCUSSION: No recommended practice yet exists for disinfection of mobile phones in the acute care setting. The disinfection method and routine used in this study may have implications for use in acute care settings to reduce opportunities for infectious disease transmission.

Symptom Assessment for Mechanically Ventilated Patients: Principles and Priorities: An Official American Thoracic Society Workshop Report.

Mechanically ventilated patients experience many adverse symptoms, such as anxiety, thirst, and dyspnea. However, these common symptoms are not included in practice guideline recommendations for routine assessment of mechanically ventilated patients. An American Thoracic Society-sponsored workshop with researchers and clinicians with expertise in critical care and symptom management was convened for a discussion of symptom assessment in mechanically ventilated patients. Members included nurses, physicians, a respiratory therapist, a speech-language pathologist, a critical care pharmacist, and a former intensive care unit patient. This report summarizes existing evidence and consensus among workshop participants regarding 1) symptoms that should be considered for routine assessment of adult patients receiving mechanical ventilation; 2) key symptom assessment principles; 3) strategies that support symptom assessment in nonvocal patients; and 4) areas for future clinical practice development and research. Systematic patient-centered assessment of multiple symptoms has great potential to minimize patient distress and improve the patient experience. A culture shift is necessary to promote ongoing holistic symptom assessment with valid and reliable instruments. This report represents our workgroup consensus on symptom assessment for mechanically ventilated patients. Future work should address how holistic, patient-centered symptom assessment can be embedded into clinical practice.

A Step Forward for Intensive Care Unit Patients: Early Mobility Interventions and Associated Outcome Measures.

BACKGROUND: Critical illness survivors have impairments across physical, psychological, and cognitive health domains known as post-intensive care syndrome. Although physical activity can improve outcomes across all health domains, most intensive care unit early mobility studies focus solely on physical outcomes. OBJECTIVE: To explore the role of early mobility for adult patients in the intensive care unit by analyzing early mobility intervention studies with physical, psychological, or cognitive outcome measures. METHODS: This integrative review used Whittemore and Knafl's methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. CINAHL, Embase, PubMed, PsycINFO, and Scopus databases were searched for primary research articles published from 2005 through 2021 on adult intensive care unit early mobility interventions evaluated by physical, cognitive, or psychological outcome measures during or after intervention delivery. Interventions comprising only passive mobility were excluded. RESULTS: Of 1009 articles screened, 20 were included. Variations in outcome measures, measurement timing, instruments, and control groups made synthesis difficult. No study evaluated an intervention using outcome measures from all 3 health domains. Five studies measured physical and cognitive outcomes; 6 studies measured physical and psychological outcomes. CONCLUSION: Early mobility is primarily addressed objectively and unidimensionally, limiting understanding of the implications of early mobility for patients. Post-intensive care syndrome prevention begins in the intensive care unit; early mobility is a promising intervention for targeting multiple risk factors. Studies that measure outcomes in all health domains during or after early mobility are needed to better evaluate the comprehensive effects of early mobility.

Post-intensive care syndrome: A review for the primary care NP.

ABSTRACT: Post-intensive care syndrome is a costly and complicated collection of physical, cognitive, and mental health problems experienced by survivors of critical illness. The primary care NP is uniquely positioned to assess, monitor, manage, and treat patients with this syndrome following hospital discharge.

Relationships among Demographic, Clinical, and Psychological Factors Associated with Family Caregiver Readiness to Participate in Intensive Care Unit Care.

Rationale: There has been a paradigm shift to partner with family caregivers by actively involving them in the direct care of the patient throughout the critical illness trajectory. Before effectively engaging family members in patient care, clinicians must assess characteristics and circumstances that may affect caregiver readiness to assume a caregiving role in the intensive care unit (ICU). Objectives: To determine how demographic, clinical, and psychological factors are related to characteristics of family caregiver readiness to engage in ICU patient care. Methods: A convenience sample of ICU family caregivers of both adult and pediatric patients in the ICU was recruited for this cross-sectional study. Participants completed the following measures: PROMIS-29 (Patient-Reported Outcomes Measurement and Information System); HADS (Hospital Anxiety and Depression Scale); CaSES (Caregiver Self-Efficacy Scale); Prep Scale (Preparedness for Caregiving Scale); Patient Activation Measure for Caregivers; and FCMFHS (Family Caregiver's Motives for Helping Scale). Data were collected via self-report at a single time point while the caregiver was visiting the critically ill patient in the ICU. Data analysis consisted of descriptive statistics and bivariate correlations. Results: Caregivers (N = 127) were primarily White (82.7%), females (77.2%), with a mean age of 51.8 (standard deviation [SD], 15.6). Most were either spouses (37.8%) or parents (32.3%) of the patient in the ICU. Patients were primarily adult (76.4%) with a mean APACHE (Acute Physiology, Age, Chronic Health Evaluation) III of 45.9 (SD, 22.5). There were significant (P < 0.05) negative correlations between depression, anxiety, and fatigue and all subscales of self-efficacy (resilience r = -0.18 to -0.30; self-maintenance r = -0.44 to -0.63; emotional connectivity r = -0.27 to -0.41; instrumental giving r = -0.34 to -0.46). Caregiver depression was negatively correlated with caregiver activation (r = -0.199) and caregiver preparedness (r = -0.300). Social satisfaction was positively correlated (P < 0.05) with caregiving preparedness, motivation, and all subscales of self-efficacy (preparedness r = 0.19; motivation r = 0.24; resilience r = 0.21; self-maintenance r = 0.49; emotional connectivity r = 0.29; instrumental giving r = 0.36). Conclusions: We found that caregiver symptoms of depression, anxiety, and fatigue are inversely related to caregiver preparation, motivation, and self-efficacy. To develop effective interventions for ICU family caregivers, further research is needed to understand the relationship between caregiver well-being, caregiving readiness, and caregiver involvement in patient care.

Family Caregiver Preferences and Contributions Related to Patient Care in the ICU.

Guided by Individual and Family Self-Management Theory, the purpose of this cross-sectional study was to describe patient care activities that family caregivers endorsed and performed while visiting their family member in the ICU. We found that caregivers wanted to be involved in ICU patient care and had preferences for the care they wanted to perform with their critically ill family member. More than 80% preferred to perform tasks related to daily grooming, communication, and education. Of note, many caregivers expressed interest in holistic healing activities (i.e., music and art), and yet, less than 50% of caregivers reported participating in these activities. The discrepancy between the number of care activities that respondents desired to perform compared to the number of care activities they reported performing represents an important opportunity to shift research and practice improvement efforts toward more tailored family engagement interventions and recognition of family caregivers as essential partners in care.

The Emerging Scholars' Network Within MNRS: From Acorns to Oaks.

As the nursing faculty shortage persists, there is an urgent need to develop emerging nurse scholars into research leaders capable of advocating for the profession and expanding on the mission to improve health. To address this need, the Midwest Nursing Research Society (MNRS) commissioned a student task force that led to the development of the Emerging Scholars Network (ESN). The purpose of this article is to describe how the ESN was developed, integrated, and promoted within the MNRS to advance the overall mission and sustainability of the society. The establishment and success of the ESN is described using the Five Developmental Stages of Organization Evolution. These stages include the following: (a) Developing a Concept; (b) Launching a Start-Up; (c) Establishing Credibility; (d) Creating Sustainability; and (e) Road to Maturing and Legacy. Recommendations for continued development of the ESN are provided.

Nursing Research Priorities in Critical Care, Pulmonary, and Sleep: International Delphi Survey of Nurses, Patients, and Caregivers.

The objective of this workshop was to determine current nursing research priorities in critical care, adult pulmonary, and sleep conditions through input from consumer (patient, family, and formal and informal caregivers) and nursing experts around the world. Working groups composed of nurses and patients selected potential research priorities based on patient insight and a literature review of patient-reported outcomes, patient-reported experiences, and processes and clinical outcomes in the focal areas. A Delphi consensus approach, using a qualitative survey method to elicit expert opinion from nurses and consumers was conducted. Two rounds of online surveys available in English, Spanish, and Chinese were completed. A 75% or greater threshold for endorsement (combined responses from nursing and consumer participants) was determined a priori to retain survey items. A total of 837 participants (649 nurses and 188 patients, family, and/or caregivers) from 45 countries responded. Survey data were analyzed and nursing research priorities that comprise 23 critical care, 45 adult pulmonary, and 16 sleep items were identified. This project was successful in engaging a wide variety of nursing and consumer experts, applying a patient-reported outcome/patient-reported experience framework for organizing and understanding research priorities. The project outcome was a research agenda to inform, guide, and aid nurse scientists, educators, and providers, and to advise agencies that provide research and program funding in these fields.

Nurses' Attitudes and Practices Related to Sedation: A National Survey.

BACKGROUND: Nurses are fundamental to the implementation of sedation protocols for patients receiving mechanical ventilation. A 2005 survey showed that nurses' attitudes toward sedation affected their sedation practices. Since then, updated guidelines on managing pain, agitation, and delirium have been published. OBJECTIVE: To explore nurses' self-reported attitudes and practices related to sedation and determine whether they have changed in the past decade. METHODS: Members of the American Association of Critical-Care Nurses were invited to complete the Nurse Sedation Practices Scale, which measures nurses' self-reported sedation practices and factors that affect them. Item and subscale responses were analyzed, and differences in item responses by respondent characteristics were determined. RESULTS: Respondents (N = 177) were mostly staff nurses (68%) with a bachelor's degree in nursing (63%). Nurses' attitudes toward the effectiveness of sedation in relieving patients' distress during mechanical ventilation correlated positively with their intention to administer sedatives (r s = 0.65). Sixty-six percent of nurses agreed that sedation was necessary for patients' comfort, and 34% agreed that limiting patients' recall was a desired outcome of sedation. Respondents with more experience or CCRN certification had a less positive evaluation of the effectiveness of sedation in minimizing distress. CONCLUSIONS: Nurses' attitudes toward sedating patients receiving mechanical ventilation have shifted in the past decade, with fewer nurses now believing that all patients should be sedated. However, more than half of nurses still agree that sedation is needed for patients' comfort, highlighting the need to consider nurses' attitudes when seeking to optimize sedation practices during mechanical ventilation.

End-of-Life Decision Support in the ICU: Where Are We Now?

Determining effective decision support strategies that enhance quality of end-of-life decision making in the intensive care unit is a research priority. This systematic review identified interventional studies describing the effectiveness of decision support interventions administered to critically ill patients or their surrogate decision makers. We conducted a systematic literature search using PubMed, CINAHL, and Cochrane. Our search returned 121 articles, 22 of which met the inclusion criteria. The search generated studies with significant heterogeneity in the types of interventions evaluated and varied patient and surrogate decision-maker outcomes, which limited the comparability of the studies. Few studies demonstrated significant improvements in the primary outcomes. In conclusion, there is limited evidence on the effectiveness of end-of-life decision support for critically ill patients and their surrogate decision makers. Additional research is needed to develop and evaluate innovative decision support interventions for end-of-life decision making in the intensive care unit.

A qualitative study of factors that influence active family involvement with patient care in the ICU: Survey of critical care nurses.

OBJECTIVE: Family caregiver involvement may improve patient and family outcomes in the intensive care unit. This study describes critical care nurses' approaches to involving family caregivers in direct patient care. RESEARCH METHODOLOGY & DESIGN: This is a qualitative content analysis of text captured through an electronic survey. SETTING: A convenience sample of 374 critical care nurses in the United States who were subscribers to one of the American Association of Critical Care Nurses social media sites or electronic newsletters. MAIN OUTCOME MEASURE: Critical care nurses' responses to five open-ended questions about their approaches to family involvement in direct patient care. FINDINGS: Nurse, patient and family caregiver factors intersected in the context of the professional practice environment and the available resources for family care. Two main themes were identified: "Involving family caregivers in patient care in the intensive care unit requires careful ssessment" and "There are barriers and facilitators to caregiver involvement in patient care in the intensive care unit." CONCLUSION: Patient care demands, the professional practice environment and a lack of resources for families hindered nursing family caregiver involvement. Greater attention to these barriers as they relate to family caregiver involvement and clinical outcomes should be a priority in future research.

Letting the Patient Decide: A Case Report of Self-Administered Sedation During Mechanical Ventilation.

It is common for critical care nurses to administer sedative medications to patients receiving mechanical ventilation. Although patient-controlled analgesia is frequently used in practice to promote effective self-management of pain by patients, it is not known if patient-controlled sedation can be used to promote effective self-management of distressing symptoms associated with mechanical ventilation. A randomized pilot trial was conducted to evaluate whether patient self-administered sedation with dexmedetomidine is safe and acceptable for self-management of anxiety during ventilator support. This case report details the experiences of one patient enrolled in the pilot trial who was randomly assigned to the experimental dexmedetomidine intervention, completed the study protocol, and provided feedback. In a poststudy survey, the patient responded positively to the use of self-administered sedation with dexmedetomidine during ventilator support.