Effect of a Standardized Family Participation Program in the ICU: A Multicenter Stepped-Wedge Cluster Randomized Controlled Trial.

OBJECTIVES: To determine the effect of a standardized program for family participation in essential care activities in the ICU on symptoms of anxiety, depression, posttraumatic stress and satisfaction among relatives, and perceptions and experiences of ICU healthcare providers (HCPs). DESIGN: Multicenter stepped-wedge cluster randomized controlled trial. SETTING: Seven adult ICUs, one university, and six general teaching hospitals. PARTICIPANTS: Three hundred six relatives and 235 ICU HCPs. INTERVENTIONS: A standardized program to facilitate family participation inpatient communication, amusement/distraction, comfort, personal care, breathing, mobilization, and nutrition. MEASUREMENTS AND MAIN RESULTS: Data were collected through surveys among relatives and ICU HCPs. There were no significant differences in symptoms of anxiety in relatives in the intervention period compared with the control period (median Hospital Anxiety and Depression Scale [HADS] 5 [interquartile range (IQR) 2-10] vs 6 [IQR 3-9]; median ratio [MR] 0.72; 95% CI, 0.46-1.13; p = 0.15), depression (median HADS 4 [IQR 2-6] vs 3 [IQR 1-6]; MR 0.85; 95% CI, 0.55-1.32; p = 0.47) or posttraumatic stress (median Impact of Event Scale-Revised score 0.45 [IQR 0.27-0.82] vs 0.41 [IQR 0.14-1]; MR 0.94; 95% CI, 0.78-1.14; p = 0.54). Reported satisfaction was slightly lower in the intervention period (mean 8.90 [ sd 1.10] vs mean 9.06 [ sd 1.10], difference -0.60; 95% CI, -1.07 to -0.12; p = 0.01). ICU HCPs perceived that more relatives knew how to participate: 47% in the intervention period versus 22% in the control period (odds ratio [OR] 3.15; 95% CI, 1.64-6.05; p < 0.01). They also reported relatives having sufficient knowledge (41% vs 16%; OR 3.56; 95% CI, 1.75-7.25; p < 0.01) and skills (44% vs 25%; OR 2.38; 95% CI, 1.22-4.63; p = 0.01) to apply family participation. CONCLUSIONS: Application of a standardized program to facilitate family participation did not change mental health symptoms in relatives of ICU patients 3 months after discharge. ICU HCPs reported increased clarity, knowledge, and skills among relatives and ICU HCPs.

Exploring patients' and relatives' needs and perceptions regarding family participation in essential care in the intensive care unit: A qualitative study.

OBJECTIVES: To examine the needs, perceptions and influencing factors according to former adult intensive care unit patients and relatives with regard to family participation in essential care in the unit. RESEARCH DESIGN: A qualitative interpretive descriptive study using inductive thematic analysis. SETTING: Twelve pairs of former Dutch patients and their relatives were interviewed within two months after the patient's discharge from the unit between December 2017 and April 2018. FINDINGS: Four themes emerged: the family's history, the patient's condition, supporting the patient and supporting the relative. The family's history, in particular the relationship with the patient and former experience with care, determined the level of participation in essential care. The level of participation was also influenced by the patient's condition, more specifically level of consciousness, stability of the patient's situation and length of the patient's stay. The third theme, supporting the patient, related to presence/being able to 'be there' for the patient and a mostly positive attitude towards family participation. The last theme was supporting the relative, with three subthemes associated with relatives' needs and perceptions: (dis)comfort with participation in essential care, need for invitation and support, and concern about the possible strain experienced by relatives. CONCLUSION: Supporting the patient and supporting the relative are reflecting the needs and perceptions of patients and relatives regarding family participation in essential care. Both the family's history and the patient's condition influence the relative's level of participation. Intensive care unit nurses and other healthcare providers could take these themes into account when encouraging family participation in essential care. IMPLICATIONS FOR CLINICAL PRACTICE: Patients' and relatives' needs and perceptions of family participation in essential care in the intensive care unit vary. Family participation in essential care is influenced by the family's history and the patient's condition. Healthcare providers could take these findings into account when implementing family participation in essential care.

Family participation in essential care activities in adult intensive care units: An integrative review of interventions and outcomes.

AIMS AND OBJECTIVES: To systematically review interventions and outcomes regarding family participation in essential care in adult intensive care units. BACKGROUND: Patients and relatives may benefit from family participation in essential care activities. DESIGN: An integrative literature review. METHODS: The following databases were systematically searched from inception to January 25, 2021: PubMed, CINAHL, EMBASE, MEDLINE, Cochrane, Web of Science and reference lists of included articles. Studies were included when reporting on family participation in essential care activities in intensive care including interventions and outcomes. Quality of the studies was assessed with the Kmet Standard Quality Assessment Criteria. Interventions were assessed, using the TIDieR framework. Data were extracted and synthesised narratively. RESULTS: A total of 6698 records were screened, and 322 full-text studies were assessed. Seven studies were included, describing an intervention to support family participation. Four studies had a pretest-posttest design, two were pilot feasibility studies and one was observational. The quality of the studies was poor to good, with Kmet-scores: 0.50-0.86 (possible score: 0-1, 1 being the highest). Five studies offered various essential care activities. One study provided sufficient intervention detail. Outcome measures among relatives varied from mental health symptoms to satisfaction, supportiveness, comfort level and experience. Two studies measured patient outcomes: delirium and pressure ulcers. Among ICU healthcare providers, perception, comfort level and experience were assessed. Since outcome measures varied, only narrative synthesis was possible. Family participation is associated with a reduction of anxiety and PTSD symptoms. CONCLUSION: Intervention descriptions of family participation in essential care activities are generally inadequate and do not allow comparison and replication. Participation of relatives was associated with a significant reduction in mental health symptoms. Other outcome measures varied, therefore, the use of additional outcome measures with validated measurement instruments should be considered. RELEVANCE TO CLINICAL PRACTICE: The review contributed further insight into interventions aiming at family participation in essential care activities in the intensive care unit and their outcomes. NO PATIENT OR PUBLIC CONTRIBUTION: Neither patients nor public were involved.

Family participation in essential care activities: Needs, perceptions, preferences, and capacities of intensive care unit patients, relatives, and healthcare providers-An integrative review.

BACKGROUND: Family participation in essential care activities may benefit both patients and relatives. OBJECTIVES: In this integrative review, we aimed to identify needs, perceptions, preferences, and capacities regarding family participation in essential care in intensive care units (ICUs) from the patient's, relatives', and ICU healthcare providers' perspective. REVIEW METHOD USED: An integrative review method was used. DATA SOURCES: PubMed, CINAHL, EMBASE, MEDLINE, Cochrane, Web of Science, and reference lists of included articles were searched, from inception to January 25, 2021. REVIEW METHODS: We included studies on family participation in essential care activities during ICU stay which reported associated needs, perceptions, preferences and capacities. Quality assessment was performed with the Kmet Standard Quality Assessment Criteria developed for evaluating primary research papers in a variety of fields, and an extensive qualitative thematic analysis was performed on the results. RESULTS: Twenty-seven studies were included. Quality scores varied from 0.45 to 0.95 (range: 0-1). Patients' needs, perceptions, preferences, and capacities are largely unknown. Identified themes on needs and perceptions were relatives' desire to help the patient, a mostly positive attitude among all involved, stress regarding patient safety, perceived beneficial effects, relatives feeling in control-ICU healthcare providers' concerns about loss of control. Preferences for potential essential care activities vary. Relatives want an invitation and support from ICU healthcare providers. Themes regarding capacities were knowledge, skills, education and training, and organisational conditions. CONCLUSIONS: Implementation of family participation in essential care requires education and training of relatives and ICU healthcare providers to address safety and quality of care concerns, though most studies lack further specification.

Effectiveness of supporting intensive care units on implementing the guideline 'End-of-life care in the intensive care unit, nursing care': a cluster randomized controlled trial.

AIM: The aim of this study was to examine the effectiveness of supporting intensive care units on implementing the guidelines. BACKGROUND: Quality of care can be achieved through evidence-based practice. Guidelines can facilitate evidence-based practice, such as the guidelines 'End-of-life care in the intensive care unit, nursing care'. Before intensive care nurses are able to use these guidelines, they needs to be implemented in clinical practice. Implementation is a complex process and may need support. DESIGN: Cluster randomized controlled trial. METHODS: Intensive care nurses of eight intensive care units in the intervention group followed a supportive programme that educated them on implementation, strategies, goals, project management and leadership. The intervention group focused on a stepwise approach to implement the guidelines. The control group (n = 5) implemented the guidelines independently or used the standard implementation plan supplementary to the guideline. The effectiveness of the programme was measured using questionnaires for nurses, interviews with nurses and a questionnaire for family of deceased patients, in the period from December 2014-December 2015. RESULTS: Overall, an increase in adherence to the guidelines was found in both groups. Overall, use of the guidelines in the intervention group was higher, but on some aspects the control group showed a higher score. Care for the patient and the overall nursing care scored significantly higher according to family in the intervention group. CONCLUSION: The increase in adherence to the guidelines and the significantly higher satisfaction of family in the intervention group indicate that the supportive programme had a more positive effect.

The role of ICU nurses in the spiritual aspects of end-of-life care in the ICU: an explorative study.

AIM: The aim of this study was to examine the role and responsibilities of intensive care unit (ICU) nurses regarding the spiritual aspects of end-of-life care in the ICU, from the chaplains' perspectives. METHOD: An explorative study including inductive thematic analysis was used. Two focus group interviews with in total eleven chaplains working in several Dutch ICUs were performed. RESULTS: The focus group interviews resulted in five themes: (i) awareness of ICU nurses, (ii) communication, (iii) nursing interventions, (iv) multidisciplinary care and (v) education. In total, twenty recommendations were formulated. CONCLUSIONS: This explorative study provides an overview of the perspectives of chaplains about the role of ICU nurses during end-of-life care, specified to spiritual care. Chaplains mentioned different roles, responsibilities and competences which are needed for ICU nurses to give spiritual care. These roles, responsibilities and competences included giving spiritual care to patients and families as standard care. Chaplains agreed that ICU nurses should start and maintain a dialogue with patient and families, but that it is also important to be aware of one's own spiritual background. However, education about spiritual care is needed to establish this. It could be recommended to educate ICU nurses during their ICU training or retraining about spiritual care and reflection.

The nursing role during end-of-life care in the intensive care unit related to the interaction between patient, family and professional: an integrative review.

AIM: The aim of this study was to explore how intensive care unit (ICU) nurses describe their role during End-of-Life Care (EOLC) in the ICU, related to the interaction between patient, family and professionals (care triad). METHOD: Three electronic databases, PubMed, CINAHL and EMBASE, and reference lists of included studies were searched for studies in English, Dutch or German between January 2002 and August 2015. Studies were included if they presented data about EOLC in the adult ICU, and the role of ICU nurses around EOLC. Quantitative and qualitative studies and opinion articles were extracted. Inductive content analysis was carried out to analyse and categorise the data. RESULTS: Twenty studies were included. Four categories emerged: care for the ICU patient, care for the family, environmental aspects of EOLC and organisational aspects of EOLC. Regarding the care triad, a gap exists between theoretical models and the actual care provided by ICU nurses during EOLC. The relational aspect of care, like aimed with care triad, is absent. CONCLUSION: The literature clearly indicates that the role of ICU nurses concerns care for the patient, family and environment. It described which care should be given, but it remains unclear how care should be given (attitude). Therefore, it is difficult for ICU nurses to provide this care. Further, it seems that care provided to family mainly consists of giving advice on how to care for the patient; care for family members themselves was only mentioned in a few studies. Therefore, it seems that family does not always receive adequate care yet, which may be helpful in preventing problems like depression, anxiety or post-traumatic stress disorder. It can be concluded that it is important for ICU nurses to be aware of the existing relationships; however, comparing the literature, care triad does not appear to be reached.

Exploring family experiences of nursing aspects of end-of-life care in the ICU: A qualitative study.

OBJECTIVES: The aim of this study was to examine the experience(s) of family with the nursing aspects of End-of-life care in the intensive care unit after a decision to end life-sustaining treatment, and to describe what nursing care was most appreciated and what was lacking. METHOD: A phenomenological approach including inductive thematic analysis was used. Twenty-six family members of deceased critically ill-patients were interviewed within two months after the patient's death about their experiences with nursing aspects of end-of-life care in the intensive care unit. FINDINGS: Most family members experienced nursing contribution to end-of-life care of the patient and themselves, especially supportive care. Families mentioned the following topics: Communication between intensive care nurses, critically ill patients and family; Nursing care for critically ill patients; Nursing care for families of critically ill patients; Pre-conditions. Families appreciated that intensive care nurses were available at any time and willing to answer questions. But care was lacking because families had for example, a sense of responsibility for obtaining information, they had problems to understand their role in the decision-making process, and were not invited by nurses to participate in the care. CONCLUSIONS: Most family appreciated the nursing EOLC they received, specifically the nursing care given to the patient and themselves. Some topics needed more attention, like information and support for the family.

The effects of music on physiological responses and sedation scores in sedated, mechanically ventilated patients.

AIMS AND OBJECTIVES: A pilot study designed as future randomised controlled trial was carried out to determine the effects of music on physiological responses and sedation scores in sedated, mechanically ventilated patients. BACKGROUND: Mechanically ventilated ICU patients, even when receiving intravenous sedatives, may experience stress and anxiety. One possible intervention to reduce stress and anxiety is listening to music. DESIGN: A randomised controlled trial design with repeated measures was used. METHODS: Data were collected over a six-month period in 2006. Twenty subjects were randomly assigned to either the experimental or control group. Subjects in the experimental group listened to music three times for 30 minutes over two days; subjects in the control group undertook three 30 minute rest periods. Physiological effects of music on systolic, diastolic and mean arterial blood pressure and heart and respiratory rate were assessed. Sedation scores were also measured. RESULTS: Physiological parameters did not show a significant difference between the groups. Patients in the experimental group showed significantly higher Ramsay (sedation) scores than patients in the control group after the first session. The higher scores indicate that patients were less responsive to external stimuli. CONCLUSION: Our results suggest that listening to music leads to higher sedation scores in sedated, mechanically ventilated ICU patients. No significant decreases in physiological parameters were observed. Listening to music showed no negative changes in the condition of these patients. Future research should focus on the use of other measures, such as stress hormones, to assess stress in sedated, mechanically ventilated ICU patients. RELEVANCE TO CLINICAL PRACTICE: For the sedated, mechanically ventilated ICU patient, the benefit of music may lie in the associated (deeper) level of sedation that is achieved, which in turn may make the patient less susceptible to stress and anxiety.

Strategies to promote adherence to antiretroviral therapy applied by Dutch HIV nurse consultants: a descriptive qualitative study.

This study describes strategies used by Dutch HIV nurse consultants to promote adherence to antiretroviral therapy (ART) and the assumptions on which these strategies were based. The study used a descriptive qualitative design with individual and focus group interviews. Individual semi-structured interviews (n = 23) focusing on adherence-supporting procedures and case-based focus groups (3 groups with 5-7 participants each) focusing on adherence strategies were held with HIV nurse consultants (n = 19). The strategies described were mainly based on experience. Theoretical principles were rarely discussed and participants seldom referred to the literature. Adherence-promoting strategies were identified for two phases: (a) before beginning ART and (b) during follow-up care while on ART. Strategies that were not used in one specific phase were categorized under "all phases." Data yielded useful ideas for the care of HIV-infected patients, and findings can be applied to the development and use of adherence-promoting strategies.

The role of HIV nursing consultants in the care of HIV-infected patients in Dutch hospital outpatient clinics.

OBJECTIVE: In the Netherlands HIV nursing consultants have participated in HIV-care since 1985; their profession has changed with developments in HIV-treatment over time. The study goal was to gather information about their role in HIV-care and to provide an useful example to other (HIV-)care settings over the world. METHODS: Interviews were held with HIV nursing consultants from all AIDS treatment centres. Descriptive analyses and statistical tests to detect differences between centres categorized by care model (parallel/unstructured/alternating), were performed. RESULTS: 58% centres perform substitution of care. HIV nursing consultants see almost all patients at least once a year and see all patients when treatment is started/altered. The frequency of consultations for HIV-patients in stable condition varies, 2-4 times a year. Substitution leads to a slight, non-significant decrease in number of consultations. Adherence support is provided at the start of and during treatment. Regular patient discussions are common. All respondents are acquainted with the guidelines. Detailed knowledge of the adherence issues is limited: 58.3% had read the adherence chapter. CONCLUSION: Substitution of care model is an appropriate and effective method for the management of HIV-infected patients. PRACTICE IMPLICATIONS: Further development of and research into this new role of HIV nurse consultants is appropriate.