The parent perspective on paediatric delirium and an associated care bundle: A qualitative study.

AIMS: To explore how parents experienced their child with delirium and how parents viewed our delirium management bundle. DESIGN: We conducted a qualitative exploratory descriptive study using semi-structured individual or dyad interviews. METHODS: Twelve semi-structured interviews with 16 parents of 12 critically ill children diagnosed with delirium in a paediatric intensive care unit were conducted from October 2022 to January 2023 and analysed through a reflexive thematic analysis. FINDINGS: We generated five themes: (1) knowing that something is very wrong, (2) observing manifest changes in the child, (3) experiencing fear of long-term consequences, (4) adding insight to the bundle, and (5) family engagement. CONCLUSION: The parents in our study were able to observe subtle and manifest changes in their child with delirium. This caused fear of lasting impact. The parents regarded most of the interventions in the delirium management bundle as relevant but needed individualization in the application. The parents requested more information regarding delirium and a higher level of parent engagement in the care of their child during delirium. IMPACT: This paper contributes to understanding how parents might experience delirium in their critically ill child, how our delirium management bundle was received by the parents, and their suggestions for improvement. Our study deals with critically ill children with delirium, their parents, and staff working to prevent and manage paediatric delirium (PD) in the paediatric intensive care unit. REPORTING METHOD: The consolidated criteria for reporting qualitative research guidelines were used to ensure the transparency of our reporting. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution to the research design. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL COMMUNITY?: - It increases awareness of the parent's perspective on PD in critically ill children. - It shows how PD might affect parents, causing negative emotions such as distress, frustration, and fear of permanent damage. - It shows that the parents in our study, in addition to the care bundle, requested more information on delirium and more involvement in the care of their delirious child.

Prospective validation of Sophia observation withdrawal symptoms: A paediatric delirium scale in critically ill children in Denmark.

BACKGROUND: Paediatric delirium (PD) is increasingly recognised as a common disorder in critically ill children with a reported prevalence ranging from 9% to 66%. We validated the PD component of the Sophia Observation withdrawal Symptoms-Paediatric Delirium (SOS-PD) scale in a Danish setting to provide increased awareness and reliable identification of this critical condition, thereby paving the way for improved pathways to targeted delirium care. OBJECTIVE: The objectives of this study were to criterion validate the PD component of the SOS-PD screening tool by comparing blinded psychiatric and nurse assessments and to estimate the prevalence of delirium in critically ill children in a Danish context. METHODS: A prospective observational study was performed on critically ill children aged between 3 m and 18 y, admitted to an intensive care unit, with a hospital stay of 48 h or more. Assessments took place on a fixed weekday over an 18-month period. To test accuracy and criterion validity, bedside nurses' SOS-PD assessments were compared to the reference standard, a diagnostic assessment performed by a child psychiatrist according to the Diagnostic and Statistical Manual-V criteria by use of the Vanderbilt Assessment of Delirium in Infants and Children. RESULTS: We included 141 children in the study, 30 (21%) of whom were diagnosed with delirium by the child psychiatrist. The accuracy of the delirium diagnosis was 93.6% (95% confidence interval [CI]: 88.3-97.1) among the nurses' SOS-PD assessments compared to the reference standard. The SOS-PD demonstrated a high sensitivity of 83.3% (95% CI: 65.3-94.4) and a high specificity of 96.4% (95% CI: 91.0-99.0) with five false-negative and four false-positive cases. CONCLUSION: The PD component of the SOS-PD tool has good accuracy and validity for assessments performed by nurses compared to a child psychiatrist's diagnosis in critically ill children in a Danish setting. We recommend the use of the SOS-PD instrument in clinical practice.

Patient and public involvement in Nordic healthcare research: a scoping review of contemporary practice.

BACKGROUND: Over the past decades, there has been a growing international interest in user involvement in healthcare research. However, evidence on the management and impact of patient and public involvement in Nordic healthcare research remains limited. OBJECTIVE: The aim was to explore and delineate the current state, practice, and impact of patient and public involvement in healthcare research across different areas of healthcare and patient populations in the Nordic countries. METHODS: We conducted a scoping review using nine scientific databases and gray literature from 1992-2023. Sources were categorized as empirical or non-empirical. We used the Guidance for Reporting Involvement of Patients and the Public Short Form 2 checklist for reporting of patient and public involvement in healthcare research and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. RESULTS: A total of 56 publications were included, consisting of 39 empirical and 17 non-empirical sources. Gray literature varied among countries and institutions encompassing different types of documents. We found an increase in the number of publications on patient and public involvement in Nordic healthcare research. This was evidenced by the growing number of references and institutional initiatives intended at involving the public, indicating the increasing emphasis on patient and public involvement in Nordic healthcare research. The terminology used to describe patient and public involvement varied over time. However, there has been a gradual narrowing down of terms as the concept of PPI has become more integrated into research practices, particularly with the involvement of funding agencies. CONCLUSION: The utilization of patient and public involvement in Nordic healthcare research has substantially increased, proliferated, and gained widespread acceptance across diverse healthcare domains. The variety of approaches challenged our scoping review in terms of systematic description and impact. Patient and public involvement was applied in one or more research stages using different methodologies and terms. International agreement on terms and definitions is needed for reliable interpretation of the use of patient and public involvement in Nordic healthcare research.

Over the past decades the importance of involving patients and the public as active partners in healthcare research has received growing acknowledgement internationally. Nonetheless, our knowledge regarding the degree of patient and public involvement (PPI) in the Nordic countries remains limited. This paper addresses this gap by investigating the status, management, and influence of PPI in healthcare research within the Nordic countries. The review of these aspects has given us a better understanding of PPI and its effects on healthcare research in the Nordic region. We looked at scientific databases and webpages including research papers, commentaries, and other materials from Denmark, Norway, Sweden, Finland, and Iceland. Our goal was to gather information and provide a thorough overview of PPI practices. Our findings showed that PPI is growing with gained acceptance across different areas of health research. PPI was used at different stages of the research process, but there wasn't a common agreement on its importance and the additional value it brings to the quality of research. The study was challenged by the many different terms and definitions, which affected the clarity of our study's purpose (or goals).However, we made efforts to address this by carefully reviewing the different terms and definitions used in the literature, striving to capture the essence of PPI in our analysis. By acknowledging this variation, we aimed to provide a wide-ranging overview while identifying the complexities and nuances related with PPI in the Nordic healthcare research. We assume that achieving international agreement on terms and definitions of PPI would certainly improve the trustworthiness in future reviews.

Family presence during resuscitation.

BACKGROUND: Patients and their relatives often expect to be actively involved in decisions of treatment. Even during resuscitation and acute medical care, patients may want to have their relatives nearby, and relatives may want to be present if offered the possibility. The principle of family presence during resuscitation (FPDR) is a triangular relationship where the intervention of family presence affects the healthcare professionals, the relatives present, and the care of the patient involved. All needs and well-being must be balanced in the context of FPDR as the actions involving all three groups can impact the others. OBJECTIVES: The primary aim of this review was to investigate how offering relatives the option to be present during resuscitation of patients affects the occurrence of post-traumatic stress disorder (PTSD)-related symptoms in the relatives. The secondary aim was to investigate how offering relatives the option to be present during resuscitation of patients affects the occurrence of other psychological outcomes in the relatives and what effect family presence compared to no family presence during resuscitation of patients has on patient morbidity and mortality. We also wanted to investigate the effect of FPDR on medical treatment and care during resuscitation. Furthermore, we wanted to investigate and report the personal stress seen in healthcare professionals and if possible describe their attitudes toward the FPDR initiative. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to 22 March 2022 without any language limits. We also checked references and citations of eligible studies using Scopus, and searched for relevant systematic reviews using Epistomonikos. Furthermore, we searched ClinicalTrials.gov, WHO ICTRP, and ISRCTN registry for ongoing trials; OpenGrey for grey literature; and Google Scholar for additional trials (all on 22 March 2022). SELECTION CRITERIA: We included randomized controlled trials of adults who have witnessed a resuscitation attempt of a patient (who was their relative) at the emergency department or in the pre-hospital emergency medical service.  The participants of this review included relatives, patients, and healthcare professionals during resuscitation.  We included relatives aged 18 years or older who have witnessed a resuscitation attempt of a patient (who is their relative) in the emergency department or pre-hospital. We defined relatives as siblings, parents, spouses, children, or close friends of the patient, or any other descriptions used by the study authors. There were no limitations on adult age or gender. We defined patient as a patient with cardiac arrest in need of cardiopulmonary resuscitation (CPR), a patient with a critical medical or traumatic life-threatening condition, an unconscious patient, or a patient in any other way at risk of sudden death. We included all types of healthcare professionals as described in the included studies. There were no limitations on age or gender. DATA COLLECTION AND ANALYSIS: We checked titles and abstracts of studies identified by the search, and obtained the full reports of those studies deemed potentially relevant. Two review authors independently extracted data. As it was not possible to conduct meta-analyses, we synthesized data narratively. MAIN RESULTS: The electronic searches yielded a total of 7292 records after deduplication. We included 2 trials (3 papers) involving a total of 595 participants: a cluster-randomized trial from 2013 involving pre-hospital emergency medical services units in France, comparing systematic offer for a relative to witness CPR with the traditional practice, and its 1-year assessment; and a small pilot study from 1998 of FPDR in an emergency department in the UK. Participants were 19 to 78 years old, and between 56% and 64% were women. PTSD was measured with the Impact of Event Scale, and the median score ranged from 0 to 21 (range 0 to 75; higher scores correspond to more severe disease). In the trial that accounted for most of the included participants (570/595), the frequency of PTSD-related symptoms was significantly higher in the control group after 3 and 12 months, and in the per-protocol analyses a significant statistical difference was found in favor of FPDR when looking at PTSD, anxiety and depression, and complicated grief after 1 year.  One of the included studies also measured duration of patient resuscitation and personal stress in healthcare professionals during FPDR and found no difference between groups. Both studies had high risk of bias, and the evidence for all outcomes except one was assessed as very low certainty. AUTHORS' CONCLUSIONS: There was insufficient evidence to draw any firm conclusions on the effects of FPDR on relatives' psychological outcomes.   Sufficiently powered and well-designed randomized controlled trials may change the conclusions of the review in future.

Finding the right words: A focus group investigation of nurses' experiences of writing diaries for intensive care patients with a poor prognosis.

BACKGROUND: The overall purpose of diaries written during an intensive care stay is to help patients fill in memory gaps from the illness trajectory, which might promote long-term psychological recovery. Diaries have also been shown to benefit nurses in maintaining a view of the patient as a person in the highly technical environment and to promote reflection. There is a lack of research on how nurses might be affected by writing a diary for critically ill patients with a poor prognosis. OBJECTIVES: The aim of this study was to investigate nurses' experience of writing diaries for intensive care patients with a poor prognosis. METHODS: This study has a qualitative descriptive design and was inspired by the methodology of interpretive description. Twenty-three nurses from three Norwegian hospitals with a well-established practice of writing diaries participated in four focus groups. Reflexive thematic analysis was used. The study was reported according to the Consolidated Criteria for Reporting Qualitative Research checklist. FINDINGS: The overarching theme resulting from our analysis was "Finding the right words". This theme represents the challenge of writing in view of the uncertainty of the patient's survival and of who would read the diary. It was important to strike the right tone with these uncertainties in mind. When the patient's life could not be saved, the purpose of the diary expanded to comforting the family. To put an extra effort into making the diary something special when the patient was dying was also a meaningful activity for the nurses. CONCLUSIONS: Diaries may serve other purposes than helping patients to understand their critical illness trajectory. In cases of a poor prognosis, nurses adapted their writing to comfort the family rather than informing the patient. Diary writing was meaningful for the nurses in managing care of the dying patient.

A qualitative study of the experiences of relatives to brought in dead persons in an emergency department.

AIMS: The aim was to explore the experiences of relatives seeing and saying goodbye to brought in dead persons in a Danish emergency department. DESIGN: This was a qualitative study based on interpretive description methodology. METHODS: Data were collected through semi-structured individual interviews with relatives (n = 11) of brought in dead persons and 30 h of participatory observations of these relatives visiting the emergency department to see and say goodbye to the deceased. Data were collected between February 2019 and December 2020. RESULTS: Our analyses revealed internal and external chaos as an overarching theme, covering 4 themes and 10 subthemes. The four themes were traumatic events, restricted access, briefly being together again, and final goodbyes and departures. CONCLUSION: Emergency departments were highly acute and busy settings that prioritized survival more than the care of deceased people and their relatives. The relatives were, in every way, affected by internal and external chaos; the external chaos in the emergency department reinforced the feeling of internal chaos. It is necessary for managers and nurses in emergency departments to organize and practice care for relatives, whilst bringing in deceased individuals in a less chaotic and more caring manner. IMPACT: This study contributes to the knowledge of relatives' experiences regarding brought in dead persons, underpinning the need to care for this subpopulation in emergency departments. Care for relatives of brought in dead individuals has the potential to relieve suffering and prevent diseases, which are core elements of nursing.

Development of a non-pharmacologic delirium management bundle in paediatric intensive care units.

BACKGROUND: Non-pharmacologic interventions might be effective to reduce the incidence of delirium in pediatric intensive care units (PICU). AIM: To explore expert opinions and generate informed consensus decisions regarding the content of a non-pharmacologic delirium bundle to manage delirium in PICU patients. STUDY DESIGN: A two-round online Delphi study was conducted from February to April 2021. PICU experts (nurses, physicians, researchers, physical therapists, play specialists, and occupational therapists) located in Europe, North America, South America, Asia, and Australia participated. RESULTS: We developed a questionnaire based on the outcomes of a comprehensive literature search in the domains: 1) cognition support; 2) sleep support; and 3) physical activity support. Under these domains, we listed 11 strategies to promote support with 61 interventions. Participants rated the feasibility of each intervention on a 9-point Likert scale (ranging from 1 strongly disagree to 9 strongly agree). A disagreement index and panel median were calculated to determine the level of agreement among experts. In the second round, participants reassessed the revised statements and ranked the interventions in each domain in order of importance for age groups: 0-2, 3-5, and 6-18 years of age. During the first Delphi round, 53 of 74 (72%) questionnaires were completed, and in the second round 45 of 74 (61%) were completed. Five of the highest ranked interventions across the age groups were: 1) developing a daily routine, 2) adjusting light exposure according to the time of day, 3) scheduling time for sleep, 4) providing eyeglasses and hearing aids if appropriate, 5) encouraging parental presence. CONCLUSIONS: Based on expert consensus, we developed an age-specific non-pharmacologic delirium bundle of interventions to manage delirium in PICU patients. RELEVANCE TO CLINICAL PRACTICE: An age-specific Non-Pharmacological Delirium bundle is now ready to be tested in the PICU and will hopefully reduce pediatric delirium.

Clinical application of 'Sophia Observation withdrawal Symptoms-Paediatric Delirium' screening tool in Danish version: A feasibility study.

AIMS AND OBJECTIVES: The aims of the present study were investigating the feasibility of: (1) using the Danish version of Sophia Observation withdrawal Symptoms-Paediatric Delirium (SOS-PD) screening tool in clinical practice and (2) comparing SOS-PD performance to a child psychiatrist's assessment using the diagnostic criteria as a reference standard. BACKGROUND: Critically ill children risk developing delirium potentially causing discomfort and suffering. Intensive care delirium has a fluctuating course complicating detection. Systematic screening during and after intensive care is central to manage paediatric delirium. DESIGN AND METHODS: We used a descriptive and comparative design. First aim: Bedside nurses were asked to evaluate their experience of using the SOS-PD. Second aim: We compared the SOS-PD performance with the child psychiatrist assessment in 50 children aged 4 weeks to 18 years. RESULTS: Nurses found the Danish version of the SOS-PD applicable and easy to use. Of the 50 children included, 13 were diagnosed with delirium by the child psychiatrist. Consistency was found between the SOS-PD score and the child psychiatrist's assessment (88%). We found three false-negative and three false-positive SOS-PD cases. The false-negative cases could be explained by the differences in time periods for the assessments. SOS-PD assessments covered the past 4 h, whereas the psychiatric assessments covered the past 24 h. We assume the false-positive cases represent an acceptable inconsistency between the two assessment methods. CONCLUSIONS: The Danish version of the SOS-PD appeared suitable for identifying paediatric delirium. Our results emphasised the importance of assessment at least once during each nursing shift to ensure delirium detection around the clock due to the fluctuating course of delirium. RELEVANCE TO CLINICAL PRACTICE: Implementing the Danish SOS-PD may increase awareness of this critical disorder by improving systematic identification of paediatric delirium in clinical practice paving the way for improved delirium prevention and management.

A qualitative study portraying nurses' perspectives on transitional care between intensive care units and hospitals wards.

INTRODUCTION: The transition process from the intensive care unit (ICU) to hospital ward may impact the illness trajectory and compromise the continuity of safe care for ICU survivors. ICU and ward nurses are involved with the transition and are responsible for the quality of the transitional care. AIM: The aim was to explore ICU and ward nurses' views on assignments in relation to patients' transition between ICU and hospital ward. METHODS: We conducted a qualitative study with 20 semi-structured interviews with ICU nurses and ward nurses and analysed data by content analysis. SETTING: A university hospital with 690 beds and an 11-bed mixed medical/surgical ICU. FINDINGS: The overarching themes were (1) 'Ritual of hand over' with the categories: (a) 'Ready, able and willing', (b) 'Transfer of responsibility' and (c) 'Nice to know versus need to know' and (2) 'From lifesaving care to rehabilitative care' with the categories: (a) 'Complex care needs persist', (b) 'Fight or flight mode' and (c) '"Weaning" the family'. Nurses were highly focused on the ritual of the actual handover of the patient and discussed readiness as an indicator of quality and the feeling of passing on the responsibility. Nurses had different opinions on what useful knowledge was and thus necessary to communicate during handover. Although patients' complex care needs may not have been resolved when exiting the ICU, ward nurses had to receive patients in a setting where nurses were mostly comfortable within their own specialty - this was worrying for both type of nurses. Patients could enter the ward very exhausted and weak or in 'fight mode' and demand rehabilitation at a pace the ward was not capable of delivering. ICU nurses encouraged families to be demanding after the ICU stay, and ward nurses asked them to trust them and steep back.

Skills, competencies, and policies for advanced practice critical care nursing in Europe: A scoping review.

OBJECTIVES: Management of critically ill patients is changing due a rise in population age, comorbidity and complexity. To accommodate these changes, the demand is increasing for advanced practice nurses. More knowledge is needed regarding the role of advanced practice critical care nurses in European countries. The aim of the study was to review the literature describing skills and competencies required for advanced practice critical care nursing in Europe and to investigate related policy. REVIEW METHOD: We performed a scoping review including papers published in 1992-2019 targeting policy and the intersection of advanced practice nursing (level of practice), critical care nursing (specialty area) and Europe (geographical origin). DESIGN AND DATA SOURCES: Main sources of evidence were PubMed, EMBASE, PsycINFO, CINAHL, Cochrane Library, SweMed+, Scopus, ERIC and Social Sciences Citation Index. We also searched grey literature, webpages, reference lists and performed hand-search. RESULTS: The search identified 11,478 papers/references of which 42 were included. Four levels of practice were identified with unclear boundaries: professional nurse, specialized nurse, advanced practice nurse and advanced critical care practitioner (nurse or other). Most skills and competencies described in the literature were generic to advanced practice and only few were area specific to critical care. Advanced practice critical care nurses were often unable to fulfil their role because education, supportive policy and legislation were lacking. CONCLUSIONS: This scoping review informs the policy makers and the INACTIC study of existing advanced practice in critical care nursing in Europe. The advanced role in critical care nursing is characterized by inconsistency regarding policy, education, titles, roles, scope of practice, skills and competencies. Levels of practice and areas of specialization need to be clarified. Most skills and competencies identified were generic for advanced practice nursing and many were generic for any profession. Task-shifting from physician to nurse needs to be more clearly defined and patient outcomes described. Given the scarcity of papers in our target area, we believe it might be too early to conduct a systematic review at this time.

Patient Characteristics of Persons Dead on Arrival Received in a Danish Emergency Department: A Retrospective Review of Health Records.

INTRODUCTION: In addition to treating living patients, emergency nurses are also responsible for receiving and caring for persons who are dead on arrival and their relatives. There is limited knowledge about the dead on arrival patient and family population as well as care practice for the dead and their relatives. The first step in improving care for dead on arrival persons is to know the size and characteristics of the population. Therefore, the aim of this study was to describe the size and characteristics of the dead on arrival population in a Danish emergency department. METHODS: A retrospective review of health records was undertaken for all consecutive dead on arrival persons received in 1 Danish emergency department between January 2018 and December 2019. RESULTS: A total of 719 dead on arrival persons were included, 350 in 2018 and 369 in 2019. Males accounted for 64%. The mean age was 71 years with a range from 18 to 102 years. The place of death was 80% at home, and more than half (54%) were found either dead or dying by a spouse, cohabitant, or son/daughter. In most cases, the cause of death was described as unknown (92%), whereas suicide and accidents accounted for 8%. DISCUSSION: The population of dead on arrival persons in a Danish emergency department were mainly men, found dying or dead by relatives and brought in from home. Additional research and development are warranted regarding care practices for dead on arrival and their families in the emergency department.

How to care for the brought in dead and their relatives. A qualitative study protocol based on interpretive description.

AIM: This project has two aims: (a) What do relatives to brought in dead (BID) describe as helpful and supportive care when they arrive at the emergency department to see and say goodbye to a deceased? (b) What do nurses describe as good nursing practice for BID persons and their relatives and what may hinder or facilitate this practice in an emergency setting? DESIGN: A qualitative study in the methodology interpretive description. METHODS: Data will be collected through three data sources: Individual interviews with relatives to BID persons, participant observations of relatives to BID persons during their presence in the emergency department and focus group interviews with emergency nurses. DISCUSSION: Brought in dead persons and their relatives are received and cared for in emergency departments by emergency nurses. Knowledge of how to render care for the relatives to BID persons in an acute setting including what skills and competences this require of the nurses is warranted. We need to explore, describe, and comprehend the experiences of both the relatives and the nurses to point out potential areas of improvement. IMPACT: This study is a protocol of an Interpretive Description study offering insight into considerations and reflections in designing the study.

Patient and spouses experiences with transition from intensive care unit to hospital ward - qualitative study.

BACKGROUND AND PURPOSE OF STUDY: Transition from the intensive care unit to the hospital ward can be considered as a vulnerable period for patients as nursing care changes hands. How the transition is experienced by the ICU patient and the family is influenced by how it is organised, communicated and executed. The transition may positively or negatively affect patient recovery. AIM: To explore the experiences of intensive care unit patients and their relatives during the transition to hospital ward in order to find ways of supporting them during the transition process. METHODS: Eligible participants were asked for participation from April to September 2016 from a mixed medical and surgical intensive care unit (Level II) at a university hospital. We conducted six semi-structured interviews with former intensive care unit patients and four dyad interviews with patients and spouses. Data were analysed according to the methodology Interpretive Description with the aim to discover associations, relationships and patterns within the phenomenon. RESULTS: Our analysis revealed the following three themes: (1) Taking up the mantel (2) Adjusting to 'being one in the crowd' and (3) Integrated spouses became visitors. It was a change from an environment with high dependence to increasing independence and a shift from attention to loneliness. Focus moved from the bodily functions to basic activities of living. Spouses experienced that their position was reduced from integrated relatives in the intensive care unit to visitors of the hospital ward. CONCLUSIONS: This article shows that it is important to mentally prepare patients and their family for transfer and a gradual withdrawal of intense nursing observation and monitoring. Discharge planning should begin early and involve spouses to a higher extent as they have a major role in the recovery process far beyond hospitalisation.

Evidence characterising skills, competencies and policies in advanced practice critical care nursing in Europe: a scoping review protocol.

INTRODUCTION: The management of critically ill patients is challenged by increasing population age and prevalence of comorbid diseases. High-quality intensive care nursing practice is imperative to accommodate these issues. The roles of the nurse practitioner (NP) and the acute care NP have existed for decades in the USA, Canada and Australia but are still evolving in Europe. Some European countries have introduced the advanced practice nurse (APN), but the current standard of the advanced level of nursing is variable and consensus regarding the framework, role and definition is lacking. Literature and evidence are sparse as well. Identification of skills and competencies required for the APN is warranted. Mapping skills and competencies will enable future educational harmonisation and facilitate mobility of the advanced-level intensive care nursing workforce across Europe. The aim of our scoping review is to identify literature describing skills, competencies and policies characterising advanced nursing practice in intensive care across Europe. METHODS AND ANALYSIS: We will apply a five-stage scoping review methodology with a comprehensive systematic literature search as outlined by Arksey and O'Malley. In collaboration with a research librarian, we will search nine interdisciplinary databases and grey literature for publications originating in European countries in 1992-2018. Using a two-stage screening process with Covidence to remove duplicates, we will first scan the title and abstract and then perform full-text review to determine the eligibility of the papers. Qualitative content analysis will be used to chart the data. ETHICS AND DISSEMINATION: Our study is a part of the European Union-funded INACTIC project (International Nursing Advanced Competency-based Training for Intensive Care) with the overall aim of developing a common European curriculum for advanced practice critical care nursing. Results from this scoping review mapping the evidence of APNs in Europe will be presented at national and international conferences and published in a peer-reviewed journal.

Interventions for preventing intensive care unit delirium in adults.

BACKGROUND: Delirium is defined as a disturbance in attention, awareness and cognition with reduced ability to direct, focus, sustain and shift attention, and reduced orientation to the environment. Critically ill patients in the intensive care unit (ICU) frequently develop ICU delirium. It can profoundly affect both them and their families because it is associated with increased mortality, longer duration of mechanical ventilation, longer hospital and ICU stay and long-term cognitive impairment. It also results in increased costs for society. OBJECTIVES: To assess existing evidence for the effect of preventive interventions on ICU delirium, in-hospital mortality, the number of delirium- and coma-free days, ventilator-free days, length of stay in the ICU and cognitive impairment. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, BIOSIS, International Web of Science, Latin American Caribbean Health Sciences Literature, CINAHL from 1980 to 11 April 2018 without any language limits. We adapted the MEDLINE search for searching the other databases. Furthermore, we checked references, searched citations and contacted study authors to identify additional studies. We also checked the following trial registries: Current Controlled Trials; ClinicalTrials.gov; and CenterWatch.com (all on 24 April 2018). SELECTION CRITERIA: We included randomized controlled trials (RCTs) of adult medical or surgical ICU patients receiving any intervention for preventing ICU delirium. The control could be standard ICU care, placebo or both. We assessed the quality of evidence with GRADE. DATA COLLECTION AND ANALYSIS: We checked titles and abstracts to exclude obviously irrelevant studies and obtained full reports on potentially relevant ones. Two review authors independently extracted data. If possible we conducted meta-analyses, otherwise we synthesized data narratively. MAIN RESULTS: The electronic search yielded 8746 records. We included 12 RCTs (3885 participants) comparing usual care with the following interventions: commonly used drugs (four studies); sedation regimens (four studies); physical therapy or cognitive therapy, or both (one study); environmental interventions (two studies); and preventive nursing care (one study). We found 15 ongoing studies and five studies awaiting classification. The participants were 48 to 70 years old; 48% to 74% were male; the mean acute physiology and chronic health evaluation (APACHE II) score was 14 to 28 (range 0 to 71; higher scores correspond to more severe disease and a higher risk of death). With the exception of one study, all participants were mechanically ventilated in medical or surgical ICUs or mixed. The studies were overall at low risk of bias. Six studies were at high risk of detection bias due to lack of blinding of outcome assessors. We report results for the two most commonly explored approaches to delirium prevention: pharmacologic and a non-pharmacologic intervention.Haloperidol versus placebo (two RCTs, 1580 participants)The event rate of ICU delirium was measured in one study including 1439 participants. No difference was identified between groups, (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.87 to 1.17) (moderate-quality evidence). Haloperidol versus placebo neither reduced or increased in-hospital mortality, (RR 0.98, 95% CI 0.80 to 1.22; 2 studies; 1580 participants (moderate-quality evidence)); the number of delirium- and coma-free days, (mean difference (MD) -0.60, 95% CI -1.37 to 0.17; 2 studies, 1580 participants (moderate-quality of evidence)); number of ventilator-free days (mean 23.8 (MD -0.30, 95% CI -0.93 to 0.33) 1 study; 1439 participants, (high-quality evidence)); length of ICU stay, (MD 0.18, 95% CI -0.60 to 0.97); 2 studies, 1580 participants; high-quality evidence). None of the studies measured cognitive impairment. In one study there were three serious adverse events in the intervention group and five in the placebo group; in the other there were five serious adverse events and three patients died, one in each group. None of the serious adverse events were judged to be related to interventions received (moderate-quality evidence).Physical and cognitive therapy interventions (one study, 65 participants)The study did not measure the event rate of ICU delirium. A physical and cognitive therapy intervention versus standard care neither reduced nor increased in-hospital mortality, (RR 0.94, 95% CI 0.40 to 2.20, I² = 0; 1 study, 65 participants; very low-quality evidence); the number of delirium- and coma-free days, (MD -2.8, 95% CI -10.1 to 4.6, I² = 0; 1 study, 65 participants; very low-quality evidence); the number of ventilator-free days (within the first 28/30 days) was median 27.4 (IQR 0 to 29.2) and 25 (IQR 0 to 28.9); 1 study, 65 participants; very low-quality evidence, length of ICU stay, (MD 1.23, 95% CI -0.68 to 3.14, I² = 0; 1 study, 65 participants; very low-quality evidence); cognitive impairment measured by the MMSE: Mini-Mental State Examination with higher scores indicating better function, (MD 0.97, 95% CI -0.19 to 2.13, I² = 0; 1 study, 30 participants; very low-quality evidence); or measured by the Dysexecutive questionnaire (DEX) with lower scores indicating better function (MD -8.76, 95% CI -19.06 to 1.54, I² = 0; 1 study, 30 participants; very low-quality evidence). One patient experienced acute back pain accompanied by hypotensive urgency during physical therapy. AUTHORS' CONCLUSIONS: There is probably little or no difference between haloperidol and placebo for preventing ICU delirium but further studies are needed to increase our confidence in the findings. There is insufficient evidence to determine the effects of physical and cognitive intervention on delirium. The effects of other pharmacological interventions, sedation, environmental, and preventive nursing interventions are unclear and warrant further investigation in large multicentre studies. Five studies are awaiting classification and we identified 15 ongoing studies, evaluating pharmacological interventions, sedation regimens, physical and occupational therapy combined or separately, and environmental interventions, that may alter the conclusions of the review in future.

First year experiences with a palliative out-patients structure for patients with COPD: a qualitative study of health professionals' expectations and experiences.

BACKGROUND: To improve the care of patients with advanced COPD and be able to address their palliative needs a new outpatient organization (CAPTAIN) was developed and implemented. CAPTAIN was inspired by best practice and existing guidelines and changed the traditional organization of an outpatient structure including the roles of nurses and doctors. Only sparse knowledge exists of the health professionals' expectations and experiences to organizational changes in an outpatient setting. This insight is necessary as health professionals are key stakeholders in implementing new structures and successfully transforming knowledge into practice. The aim of this study was to explore the health professionals' expectations and experiences of a new palliative out-patients structure for patients with advanced COPD. METHODS: The design was interpretive description as described by Thorne. Focus groups and individual interviews were conducted with pulmonary nurses, pulmonary doctors and municipality nurses from 2014 to 2016. RESULTS: The overall theme was dualism. Both nurses and doctors were pending between aspiration and concern in their expectations to the new structure, meanwhile their actual experiences were pending between perceived gain and improvements versus consequences with the new structure. Nurses' and doctors' existing practice was altered and the new structure required new ways for them to cooperate and ways in which skills from each profession were most efficiently utilized. CONCLUSION: Nurses and doctors considered the new structure as a quality boost and it fulfilled their hope of improving the quality of care offered to patients with advanced COPD, however with increased work-related stress as a derived consequence.

Total intravenous anaesthesia versus inhalational anaesthesia for adults undergoing transabdominal robotic assisted laparoscopic surgery.

BACKGROUND: Rapid implementation of robotic transabdominal surgery has resulted in the need for re-evaluation of the most suitable form of anaesthesia. The overall objective of anaesthesia is to minimize perioperative risk and discomfort for patients both during and after surgery. Anaesthesia for patients undergoing robotic assisted surgery is different from anaesthesia for patients undergoing open or laparoscopic surgery; new anaesthetic concerns accompany robotic assisted surgery. OBJECTIVES: To assess outcomes related to the choice of total intravenous anaesthesia (TIVA) or inhalational anaesthesia for adults undergoing transabdominal robotic assisted laparoscopic gynaecological, urological or gastroenterological surgery. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016 Issue 5), Ovid MEDLINE (1946 to May 2016), Embase via OvidSP (1982 to May 2016), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCOhost (1982 to May 2016) and the Institute for Scientific Information (ISI) Web of Science (1956 to May 2016). We also searched the International Standard Randomized Controlled Trial Number (ISRCTN) Registry and Clinical trials gov for ongoing trials (May 2016). SELECTION CRITERIA: We searched for randomized controlled trials (RCTs) including adults, aged 18 years and older, of both genders, treated with transabdominal robotic assisted laparoscopic gynaecological, urological or gastroenterological surgery and focusing on outcomes of TIVA or inhalational anaesthesia. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures of Cochrane. Study findings were not suitable for meta-analysis. MAIN RESULTS: We included three single-centre, two-arm RCTs involving 170 participants. We found one ongoing trial. All included participants were male and were undergoing radical robotic assisted laparoscopic radical prostatectomy (RALRP). The men were between 50 and 75 years of age and met criteria for American Society of Anesthesiologists physical classification scores (ASA) I, ll and III.We found evidence showing no clinically meaningful differences in postoperative pain between the two types of anaesthetics (mean difference (MD) in visual analogue scale (VAS) scores at one to six hours was -2.20 (95% confidence interval (CI) -10.62 to 6.22; P = 0.61) in a sample of 62 participants from one study. Low-quality evidence suggests that propofol reduces postoperative nausea and vomiting (PONV) over the short term (one to six hours after surgery) after RALRP compared with inhalational anaesthesia (sevoflurane, desflurane) (MD -1.70, 95% CI -2.59 to -0.81; P = 0.0002).We found low-quality evidence suggesting that propofol may prevent an increase in intraocular pressure (IOP) after pneumoperitoneum and steep Trendelenburg positioning compared with sevoflurane (MD -3.90, 95% CI -6.34 to -1.46; P = 0.002) with increased IOP from baseline to 30 minutes in steep Trendelenburg. However, it is unclear whether this surrogate outcome translates directly to clinical avoidance of ocular complications during surgery. No studies addressed the secondary outcomes of adverse effects, all-cause mortality, respiratory or circulatory complications, cognitive dysfunction, length of stay or costs. Overall the quality of evidence was low to very low, as all studies were small, single-centre trials providing unclear descriptions of methods. AUTHORS' CONCLUSIONS: It is unclear which anaesthetic technique is superior - TIVA or inhalational - for transabdominal robotic assisted surgery in urology, gynaecology and gastroenterology, as existing evidence is scarce, is of low quality and has been generated from exclusively male patients undergoing robotic radical prostatectomy.An ongoing trial, which includes participants of both genders with a focus on quality of recovery, might have an impact on future evidence related to this topic.

Robotic-assisted laparoscopic hysterectomy for women with endometrial cancer.

INTRODUCTION: Robotic-assisted laparoscopic hysterectomy (RALH) has become a widely used approach for women with endometrial cancer and has replaced laparotomy. It has been questioned if the increased costs are justified by superior surgical outcomes. The aim of the present study was to examine the frequency, types and severity of post-operative complications after total abdominal hysterectomy (TAH) and RALH using the Clavien-Dindo classification of surgical outcomes. METHODS: A non-randomised, controlled before and after study of 360 women was conducted; 202 underwent RALH and 158 TAH (historical controls). RESULTS: RALH had significant advantages compared with TAH: fewer and less severe post-operative complications and a shorter length of hospital stay. The absolute risk reduction for post-operative complications was 13% (95% confidence interval: 4.29-20.87%). Women treated with TAH had significantly more severe complications (grade ≥ 3) than those treated with RALH; 12% versus 3% (p = 0.001). Infections (urinary and port site) were the most frequent post-operative complications overall. The duration of RALH in the operation theatre was longer, while the duration of stay in the post-anaesthesia care unit was shorter for patients undergoing RALH. CONCLUSIONS: RALH appears advantageous for women treated for endometrial cancer in terms of post-operative complications. We recommend the use of the Clavien-Dindo classification of surgical outcomes for quality assessment. FUNDING: departmental only. TRIAL REGISTRATION: Danish Health Authority (3-2013-111/1/KAHO).

Robotic-assisted laparoscopic hysterectomy for women with endometrial cancer - complications, women´s experiences, quality of life and a health economic evaluation.

This thesis contains four studies all focusing on women with endometrial cancer undergoing robotic-assisted laparoscopic hysterectomy (RALH). Women with endometrial cancer are typically elderly with co-morbidities. RALH is a relatively new treatment option which has been introduced and adopted over the last decade without randomised controlled trials (RCTs) to prove superiority over other surgical alternatives. The purpose of the thesis was to explore and describe patient and health economic outcomes of RALH for women with endometrial cancer using different research approaches. The first study was a retrospective descriptive cohort study with 235 women. The aim was to explore types and incidence of post-operative complications within 12 months after RALH reported with the Clavien-Dindo scale. We found that 6% had severe complications and that women with lymphadenectomy did not have an increased rate of complications. Urinary tract and port site infections were the most frequent complications. The second study was a qualitative interview study where we explored the experience of undergoing RALH. Using content analysis, we analysed semi-structured interviews with 12 women who had undergone RALH on average 12 weeks earlier. The women were positive towards the robotic approach and felt recovered shortly after. They expressed uncertainty with the normal course of bleeding and bowel movement post-operatively as well as with the new anatomy. The third study was an economic evaluation; an activity-based costing study including 360 women comparing total abdominal hysterectomy (TAH) to RALH. This study showed that for women with endometrial cancer, RALH was cheaper compared to TAH, mainly due to fewer complications and shorter length of stay (LOS) that counterbalanced the higher robotic expenses. When including all cost drivers the analysis showed that the RALH procedure was more than 9.000 Danish kroner (DKK) cheaper than the TAH. Increased age and Type 2 diabetes appeared to increase costs. The fourth study was a prospective cohort study of 139 women who were followed four months after surgery with the aim to assess short term changes in health-related quality of life (HRQoL), symptoms and function after RALH. Both a general and an illness specific HRQoL questionnaire were used. The preoperative baseline measurement was compared with measurements at one and five weeks and four months post-operatively. The women also selfreported their level of activity once a week for the first five weeks after surgery. We found that HRQoL was back to baseline level at five weeks post-operatively for the majority of women. Fatigue, constipation, gastrointestinal symptoms, pain, appetite and change of taste were negatively affected short-term. At five weeks the mean level of physical activity resumed was 84%. Together, the studies indicate that RALH is a well-tolerated surgical treatment for women with endometrial cancer, and post-operative complications appear fewer and less severe compared to previous open surgery. This points towards RALH being clinically and economically efficient. The women experienced that RALH was easy to overcome and they felt recovered shortly after. However, they expressed uncertainty about the normal post-operative cause and reported changes in functions and symptoms short term after surgery. These changes should be addressed in the preoperative information and at the post-operative follow-up. It is difficult imagining a RCT of robotic-assisted laparoscopic hysterectomy being conducted in the future due to reluctance towards randomisation to open surgery. However, it would be advisable continuously to monitor relevant surgical and patient-reported outcomes as indications for robotic surgery may alter, experiences may develop and further technical advances may change robotic surgery for women with endometrial cancer in the future.

The Experience of Robotic-Assisted Laparoscopic Hysterectomy for Women Treated for Early-Stage Endometrial Cancer: A Qualitative Study.

BACKGROUND: An increasing number of women are offered robotic-assisted laparoscopic hysterectomy as treatment for early-stage endometrial cancer in the developed world. OBJECTIVE: The aim of this study was to explore how women diagnosed with early-stage endometrial cancer experienced robotic-assisted laparoscopic hysterectomy. METHODS: Semistructured interviews were carried out with 12 women, and interview data were analyzed by qualitative content analysis. RESULTS: Four overarching themes emerged: "surgery was a piece of cake," "recovering physically after surgery," "going from being off guard to being on guard," and "preparing oneself by seeking information." The women had confidence in the robotic technique and experienced fast recovery after robotic-assisted laparoscopic hysterectomy; however, they had uncertainties and unanswered questions concerning the postoperative course. Shortly after discharge, the women did not consider themselves surviving cancer patients but as cured. The women searched for information from various sources, for example, the Internet and the online patient chart, to prepare for surgery and to come to terms with the diagnosis. CONCLUSIONS: Although the women had confidence in the robotic technique and recovered quickly physically, they lacked information about what went on in the operation theatre and about their new anatomy. IMPLICATIONS FOR PRACTICE: Patient education about the normal postoperative course in regard to vaginal bleeding, bowel function, and level of physical activity is needed. Individualized information about anatomical changes after surgery is warranted, preferably using anatomical drawings. Potentially, the women could benefit from attending a nursing clinic during the first postoperative months.