Evaluating the use of casuistry during moral case deliberation in the ICU: A multiple qualitative case study.

Intensive care unit (ICU) professionals engage in ethical decision making under conditions of high stakes, great uncertainty, time-sensitivity and frequent irreversibility of action. Casuistry is a way by which actionable knowledge is obtained through comparing a patient case to previous cases from experience in clinical practice. However, within the field of study as well as in practice, evidence-based medicine is the dominant epistemic framework. This multiple case study evaluated the use of casuistic reasoning by intensive care unit (ICU) professionals during moral case deliberation. It took place in two Dutch hospitals between June 2020 and June 2022. Twentyfive moral case deliberations from ICU practice were recorded and analyzed using discourse analysis. Additionally, 47 interviews were held with ICU professionals who participated in these deliberations, analyzed using thematic analysis. We found that ICU professionals made considerable use of case comparisons when discussing continuation, withdrawal or limitation. Analogies played a role in justifying or complicating moral judgements, and also played a role in addressing moral distress. The language of case-based arguments is most often not overtly normative. Rather, the data shows that casuistic reasoning deals with the medical, ethical and contextual elements of decisions in an integrated manner. Facilitators of MCD have an essential role in (supporting ICU professionals in) scrutinizing casuistic arguments. The data shows that during MCD, actual reasoning often deviated from principle- and rule-based reasoning which ICU professionals preferred themselves. Evidence-based arguments often gained the character of analogical arguments, especially when a patient-at-hand was seen as highly unique from the average patients in the literature. Casuistic arguments disguised as evidence-based arguments may therefore provide ICU professionals with a false sense of certainty. Within education, we should strive to train clinicians and ethics facilitators so that they can recognize and evaluate casuistic arguments.

Measuring the work environment among healthcare professionals: Validation of the Dutch version of the Culture of Care Barometer.

OBJECTIVES: A positive work environment (WE) is paramount for healthcare employees to provide good quality care. To stimulate a positive work environment, employees' perceptions of the work environment need to be assessed. This study aimed to assess the reliability and validity of the Dutch version of the Culture of Care Barometer (CoCB-NL) survey in hospitals. METHODS: This longitudinal validation study explored content validity, structural validity, internal consistency, hypothesis testing for construct validity, and responsiveness. The study was conducted at seven departments in two Dutch university hospitals. The departments were included based on their managers' motivation to better understand their employees' perception of their WE. All employees of participating departments were invited to complete the survey (n = 1,730). RESULTS: The response rate was 63.2%. The content of the CoCB-NL was considered relevant and accessible by the respondents. Two factor models were found. First, confirmative factor analysis of the original four-factor structure showed an acceptable fit (X2 2006.49; df 399; p = <0.001; comparative fit index [CFI] 0.82; Tucker-Lewis index [TLI] 0.80; root mean square error of approximation [RMSEA] 0.09). Second, explanatory factor analysis revealed a five-factor model including 'organizational support', 'leadership', 'collegiality and teamwork', 'relationship with manager', and 'employee influence and development'. This model was confirmed and showed a better fit (X2 1552.93; df 395; p = < 0.00; CFI 0.87; TLI 0.86; RMSEA 0.07). Twelve out of eighteen hypotheses were confirmed. Responsiveness was assumed between the measurements. CONCLUSIONS: The CoCB-NL is a valid and reliable instrument for identifying areas needing improvement in the WE. Furthermore, the CoCB-NL appears to be responsive and therefore useful for longitudinal evaluations of healthcare employees' work environments.

Consensus-based indicators for evaluating and improving the quality of regional collaborative networks of intensive care units: Results of a nationwide Delphi study.

PURPOSE: To select a consensus-based set of relevant and feasible indicators for monitoring and improving the quality of regional ICU network collaboratives. METHODS: A three-round Delphi study was conducted in the Netherlands between April and July 2022. A multidisciplinary expert panel prioritized potentially relevant and feasible indicators in two questionnaire rounds with two consensus meetings between both rounds. The RAND/UCLA appropriateness method was used to categorize indicators and synthesize results. A core set of highest ranked indicators with consensus-based levels of relevance and feasibility were finally tested in two ICU networks to assess their measurability. RESULTS: Twenty-four indicators were deemed as relevant and feasible. Seven indicators were selected for the core set measuring the standardized mortality rate in the region (n = 1) and evaluating the presence, content and/or follow-up of a formal plan describing network structures and policy agreements (n = 3), a long-term network vision statement (n = 1), and network meetings to reflect on and learn from outcome data (n = 2). The practice tests led to minor reformulations. CONCLUSIONS: This study generated relevant and feasible indicators for monitoring and improving the quality of ICU network collaboratives based on the collective opinion of various experts. The indicators may help to effectively govern such networks.

Prediction of Long-Term Physical, Mental, and Cognitive Problems Following Critical Illness: Development and External Validation of the PROSPECT Prediction Model.

OBJECTIVES: ICU survivors often suffer from long-lasting physical, mental, and cognitive health problems after hospital discharge. As several interventions that treat or prevent these problems already start during ICU stay, patients at high risk should be identified early. This study aimed to develop a model for early prediction of post-ICU health problems within 48 hours after ICU admission. DESIGN: Prospective cohort study in seven Dutch ICUs. SETTING/PATIENTS: ICU patients older than 16 years and admitted for greater than or equal to 12 hours between July 2016 and March 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Outcomes were physical problems (fatigue or ≥ 3 new physical symptoms), mental problems (anxiety, depression, or post-traumatic stress disorder), and cognitive impairment. Patient record data and questionnaire data were collected at ICU admission, and after 3 and 12 months, of 2,476 patients. Several models predicting physical, mental, or cognitive problems and a composite score at 3 and 12 months were developed using variables collected within 48 hours after ICU admission. Based on performance and clinical feasibility, a model, PROSPECT, predicting post-ICU health problems at 3 months was chosen, including the predictors of chronic obstructive pulmonary disease, admission type, expected length of ICU stay greater than or equal to 2 days, and preadmission anxiety and fatigue. Internal validation using bootstrapping on data of the largest hospital ( n = 1,244) yielded a C -statistic of 0.73 (95% CI, 0.70-0.76). External validation was performed on data ( n = 864) from the other six hospitals with a C -statistic of 0.77 (95% CI, 0.73-0.80). CONCLUSIONS: The developed and externally validated PROSPECT model can be used within 48 hours after ICU admission for identifying patients with an increased risk of post-ICU problems 3 months after ICU admission. Timely preventive interventions starting during ICU admission and follow-up care can prevent or mitigate post-ICU problems in these high-risk patients.

[Moral injury in medicine: recognition and guidance]. / Morele schade in de geneeskunde.

Moral injury signifies a permanent mental wound characterized by feelings of guilt, shame, anger or moral disorientation. Physicians may become morally injured whenever they act in a way that conflicts with deeply held, moral beliefs. During a pandemic, a war or whenever physicians provide care to large numbers of refugees, there is a heightened risk of moral injury. These circumstances cause conditions of scarcity of personnel and resources, and urge governments and societies to sometimes ask physicians to act in manners which conflict with their moral beliefs. Moral injury can have damning consequences for the professionals involved. That is why it is essential that physicians learn to recognize the signs of moral injury within themselves and with colleagues.

Effect of Structural Moral Case Deliberation on Burnout Symptoms, Moral Distress, and Team Climate in ICU Professionals: A Parallel Cluster Randomized Trial.

OBJECTIVES: Moral case deliberation (MCD) is a team-based and facilitator-led, structured moral dialogue about ethical difficulties encountered in practice. This study assessed whether offering structural MCD in ICUs reduces burnout symptoms and moral distress and strengthens the team climate among ICU professionals. DESIGN: This is a parallel cluster randomized trial. SETTING: Six ICUs in two hospitals located in Nijmegen, between January 2020 and September 2021. SUBJECTS: Four hundred thirty-five ICU professionals. INTERVENTIONS: Three of the ICUs organized structural MCD. In three other units, there was no structural MCD or other structural discussions of moral problems. MEASUREMENTS AND MAIN RESULTS: The primary outcomes investigated were the three burnout symptoms-emotional exhaustion, depersonalization, and a low sense of personal accomplishment-among ICU professionals measured using the Maslach Burnout Inventory on a 0-6 scale. Secondary outcomes were moral distress (Moral Distress Scale) on a 0-336 scale and team climate (Safety Attitude Questionnaire) on a 0-4 scale. Organizational culture was an explorative outcome (culture of care barometer) and was measured on a 0-4 scale. Outcomes were measured at baseline and in 6-, 12-, and 21-month follow-ups. Intention-to-treat analyses were conducted using linear mixed models for longitudinal nested data. Structural MCD did not affect emotional exhaustion or depersonalization, or the team climate. It reduced professionals' personal accomplishment (-0.15; p < 0.05) but also reduced moral distress (-5.48; p < 0.01). Perceptions of organizational support (0.15; p < 0.01), leadership (0.19; p < 0.001), and participation opportunities (0.13; p < 0.05) improved. CONCLUSIONS: Although structural MCD did not mitigate emotional exhaustion or depersonalization, and reduced personal accomplishment in ICU professionals, it did reduce moral distress. Moreover, it did not improve team climate, but improved the organizational culture.

Post-intensive care syndrome in primary care: The development of new diseases and primary care services utilisation - a prospective cohort study.

BACKGROUND: Patients experience long-lasting health problems defined as post-intensive care syndrome (PICS) after Intensive Care Unit (ICU) admission. Little is known about PICS in primary care. OBJECTIVES: To investigate whether ICU survivors encounter more new International Classification of Primary Care-2 (ICPC-2) diagnoses and general practitioner (GP) contact compared to patients with similar comorbidity without ICU admission. METHODS: Prospective multicentre cohort study in three Dutch general practices. Numbers of disease-episodes and GP contacts of ICU survivors ≥ 16 years admitted between 2008 and 2017 were extracted from GPs' information systems. A non-ICU reference cohort was matched 1:1 for age, sex, follow-up period and comorbidity groups from patients' medical history. Negative binominal regression analysis was used to compare both cohorts 0-3, 3-6, 6-12 months, 1-2 and 2-5 years after ICU admission and 1 year prior to admission. RESULTS: ICU survivors (n = 199) encountered more new disease-episodes 1 year before (mean 3.97 (95% confidence interval [CI] 3.50-4.52]]; reference 2.36 [1.28-3.17]) to 2-5 years after ICU admission (3.65 [3.15-4.26]; reference 2.86 [2.52-3.22]). ICU survivors also had more GP contacts 1 year before (mean 19.61 [17.31-22.17]; reference 10.02 [7.81-12.38]) to 2-5 years after ICU admission (18.53 [15.58-21.85]; reference 12.03 [10.33-13.91]). Patients with prior ICU admission did not encounter patterns in specific ICPC-2 chapters compared to non-ICU patients. CONCLUSION: Patients admitted to the ICU encounter more new primary care disease-episodes and GP contacts. As patients present their symptoms to their GP first, it is therefore up to the GP to recognise these critical illness-related symptoms.

Time spent on documenting quality indicator data and associations between the perceived burden of documenting these data and joy in work among professionals in intensive care units in the Netherlands: a multicentre cross-sectional survey.

OBJECTIVES: The number of indicators used to monitor and improve the quality of care is debatable and may influence professionals' joy in work. We aimed to assess intensive care unit (ICU) professionals' perceived burden of documenting quality indicator data and its association with joy in work. DESIGN: Cross-sectional survey. SETTING: ICUs of eight hospitals in the Netherlands. PARTICIPANTS: Health professionals (ie, medical specialists, residents and nurses) working in the ICU. MEASUREMENTS: The survey included reported time spent on documenting quality indicator data and validated measures for documentation burden (ie, such documentation being unreasonable and unnecessary) and elements of joy in work (ie, intrinsic and extrinsic motivation, autonomy, relatedness and competence). Multivariable regression analysis was performed for each element of joy in work as a separate outcome. RESULTS: In total, 448 ICU professionals responded to the survey (65% response rate). The overall median time spent on documenting quality data per working day is 60 min (IQR 30-90). Nurses spend more time documenting these data than physicians (medians of 60 min vs 35 min, p<0.01). Most professionals (n=259, 66%) often perceive such documentation tasks as unnecessary and a minority (n=71, 18%) perceive them as unreasonable. No associations between documentation burden and measures of joy in work were found, except for the negative association between unnecessary documentations and sense of autonomy (ß=-0.11, 95% CI -0.21 to -0.01, p=0.03). CONCLUSIONS: Dutch ICU professionals spend substantial time on documenting quality indicator data they often regard as unnecessary. Despite the lacking necessity, documentation burden had limited impact on joy in work. Future research should focus on which aspects of work are affected by documentation burden and whether diminishing the burden improves joy in work.

Development and External Validation of a Prediction Model for Quality of Life of ICU Survivors: A Subanalysis of the MONITOR-IC Prospective Cohort Study.

OBJECTIVES: To develop and externally validate a prediction model for ICU survivors' change in quality of life 1 year after ICU admission that can support ICU physicians in preparing patients for life after ICU and managing their expectations. DESIGN: Data from a prospective multicenter cohort study (MONITOR-IC) were used. SETTING: Seven hospitals in the Netherlands. PATIENTS: ICU survivors greater than or equal to 16 years old. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Outcome was defined as change in quality of life, measured using the EuroQol 5D questionnaire. The developed model was based on data from an academic hospital, using multivariable linear regression analysis. To assist usability, variables were selected using the least absolute shrinkage and selection operator method. External validation was executed using data of six nonacademic hospitals. Of 1,804 patients included in analysis, 1,057 patients (58.6%) were admitted to the academic hospital, and 747 patients (41.4%) were admitted to a nonacademic hospital. Forty-nine variables were entered into a linear regression model, resulting in an explained variance ( R2 ) of 56.6%. Only three variables, baseline quality of life, admission type, and Glasgow Coma Scale, were selected for the final model ( R2 = 52.5%). External validation showed good predictive power ( R2 = 53.2%). CONCLUSIONS: This study developed and externally validated a prediction model for change in quality of life 1 year after ICU admission. Due to the small number of predictors, the model is appealing for use in clinical practice, where it can be implemented to prepare patients for life after ICU. The next step is to evaluate the impact of this prediction model on outcomes and experiences of patients.

Differences in long-term outcomes between ICU patients with persistent delirium, non-persistent delirium and no delirium: A longitudinal cohort study.

PURPOSE: Determine differences in physical, mental and cognitive outcomes 1-year post-ICU between patients with persistent delirium (PD), non-persistent delirium (NPD) and no delirium (ND). MATERIALS AND METHODS: A longitudinal cohort study was performed in adult ICU patients of two hospitals admitted between July 2016-February 2020. Questionnaires on physical, mental and cognitive health, frailty and QoL were completed regarding patients' pre-ICU health status and 1-year post-ICU. Delirium data were from patients' total hospital stay. Patients were divided in PD (≥14 days delirium), NPD (<14 days delirium) or ND patients. RESULTS: 2400 patients completed both questionnaires, of whom 529 (22.0%) patients developed delirium; 35 (6.6%) patients had PD and 494 (93.4%) had NPD. Patients with delirium (PD or NPD) had worse outcomes in all domains compared to ND patients. Compared to NPD, more PD patients were frail (34.3% vs. 14.6%, p = 0.006) and fatigued (85.7% vs. 61.1%, p = 0.012). After adjustment, PD was significantly associated with long-term cognitive impairment only (aOR 3.90; 95%CI 1.31-11.63). CONCLUSIONS: Patients with PD had a higher likelihood to develop cognitive impairment 1-year post-ICU compared to NPD or ND. Patients with PD and NPD were more likely to experience impairment on all health domains (i.e. physical, mental and cognitive), compared to ND patients.

Development of Moral Injury in ICU Professionals During the COVID-19 Pandemic: A Prospective Serial Interview Study.

OBJECTIVES: During the COVID-19 pandemic, ICU professionals have faced moral problems that may cause moral injury. This study explored whether, how, and when moral injury among ICU professionals developed in the course of the COVID-19 pandemic. DESIGN: This is a prospective qualitative serial interview study. SETTING: Two hospitals among which one university medical center and one teaching hospital in the Netherlands. SUBJECTS: Twenty-six ICU professionals who worked during the COVID-19 pandemic. INTERVENTIONS: None. MEASUREMENTS MAIN RESULTS: In-depth interviews with follow-up after 6 and 12 months. In total, 62 interviews were conducted. ICU professionals narrated about anticipatory worry about life and death decisions, lack of knowledge and prognostic uncertainty about COVID-19, powerlessness and failure, abandonment or betrayal by society, politics, or the healthcare organization, numbness toward patients and families, and disorientation and self-alienation. Centrally, ICU professionals describe longitudinal processes by which they gradually numbed themselves emotionally from patients and families as well as potentially impactful events in their work. For some ICU professionals, organizational, societal, and political responses to the pandemic contributed to numbness, loss of motivation, and self-alienation. CONCLUSIONS: ICU professionals exhibit symptoms of moral injury such as feelings of betrayal, detachment, self-alienation, and disorientation. Healthcare organizations and ICU professionals themselves should be cognizant that these feelings may indicate that professionals might have developed moral injury or that it may yet develop in the future. Awareness should be raised about moral injury and should be followed up by asking morally injured professionals what they need, so as to not risk offering unwanted help.

The implementation of nUrsiNg DEliRium preventive INterventions in the Intensive Care Unit (UNDERPIN-ICU): A qualitative evaluation.

BACKGROUND: Delirium frequently occurs in intensive care unit patients and is associated with worse outcomes. Recently, a multicomponent non-pharmacological nursing intervention program called UNDERPIN-ICU, was implemented in ten Dutch intensive care units. The program was aimed at delirium reduction by optimizing four modifiable risk factors: visual and hearing impairment, cognitive impairment, immobility, and sleep deprivation. Despite its scientific fundament and extensive implementation, this program showed no effect on delirium outcomes. OBJECTIVE: To explore factors that hindered or facilitated the application of the UNDERPIN-ICU delirium program in daily practice as experienced by healthcare professionals. METHODS: Semi-structured focus group interviews were conducted in all participating centers between April and June of 2019. Directed content and thematic analyses were applied. Interviews were coded. Codes were grouped into categories based on factors that hindered or facilitated program application. RESULTS: In total, 22 ICU nurses, 3 ICU physicians, 5 local delirium group members and one research manager participated in 10 focus group interviews. We found 41 factors that hindered or facilitated program application, grouped into five categories: interventions; individual healthcare professional; patient; implementation process; capacity for change, incentives and resources. Among the factors identified in this study, the facilitating factors included standardized interventions, a structured implementation, interactive educational meetings and, feedback and support. The hindering factors included doubts about usefulness, feasibility, the extensive number of program components, limited knowledge about the program and a focus on physical care. CONCLUSION: Factors that hindered program application may explain why the UNDERPIN-ICU program did not have positive effects on delirium outcomes. Factors that facilitated application should be strengthened in future non-pharmacological nursing interventions to prevent or reduce delirium in intensive care. REGISTRATION: ClinicalTrials.gov Identifier: NCT03002701; registration date December 26, 2016.

Adverse Events in Pediatric Critical Care Nonsurvivors With a Low Predicted Mortality Risk: A Multicenter Case Control Study.

OBJECTIVES: Some patients with a low predicted mortality risk in the PICU die. The contribution of adverse events to mortality in this group is unknown. The aim of this study was to estimate the occurrence of adverse events in low-risk nonsurvivors (LN), compared with low-risk survivors (LS) and high-risk PICU survivors and nonsurvivors, and the contribution of adverse events to mortality. DESIGN: Case control study. Admissions were selected from the national Dutch PICU registry, containing 53,789 PICU admissions between 2006 and 2017, in seven PICUs. PICU admissions were stratified into four groups, based on mortality risk (low/high) and outcome (death/survival). Random samples were selected from the four groups. Cases were "LN." Control groups were as follows: "LS," "high-risk nonsurvivors" (HN), and "high-risk survivors" (HS). Adverse events were identified using the validated trigger tool method. SETTING: Patient chart review study. PATIENTS: Children admitted to the PICU with either a low predicted mortality risk (< 1%) or high predicted mortality risk (≥ 30%). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In total, 419 patients were included (102 LN, 107 LS, 104 HN, and 106 HS). LN had more complex chronic conditions (93.1%) than LS (72.9%; p < 0.01), HN (49.0%; p < 0.001), and HS (48.1%; p < 0.001). The occurrence of adverse events in LN (76.5%) was higher than in LS (13.1%) and HN (47.1%) ( p < 0.001). The most frequent adverse events in LN were hospital-acquired infections and drug/fluid-related adverse events. LN suffered from more severe adverse events compared with LS and HS ( p < 0.001). In 30.4% of LN, an adverse event contributed to death. In 8.8%, this adverse event was considered preventable. CONCLUSIONS: Significant and preventable adverse events were found in low-risk PICU nonsurvivors. 76.5% of LN had one or more adverse events. In 30.4% of LN, an adverse event contributed to mortality.

Complex interplay between moral distress and other risk factors of burnout in ICU professionals: findings from a cross-sectional survey study.

BACKGROUND: Burnout threatens intensive care unit (ICU) professionals' capacity to provide high-quality care. Moral distress is previously considered a root cause of burnout, but there are other risk factors of burnout such as personality, work-life balance and culture. This study aimed to disentangle the associations of ICU professionals' moral distress and other risk factors with the components of burnout-emotional exhaustion, depersonalisation and personal accomplishment-suggesting informed burnout prevention strategies. METHODS: Cross-sectional survey completed in 2019 of ICU professionals in two Dutch hospitals. The survey included validated measure for burnout (the Dutch Maslach Burnout Inventory), moral distress (Moral Distress Scale), personality (short Big Five Inventory), work-home balance (Survey Work-Home Interaction Nijmegen) and organisational culture (Culture of Care Barometer). Each of the three components of burnout was analysed as a separate outcome, and for each of the components, a separate regression analysis was carried out. RESULTS: 251 ICU professionals responded to the survey (response rate: 53.3%). Burnout prevalence was 22.7%. Findings showed that moral distress was associated with emotional exhaustion (ß=0.18, 95% CI 0.9 to 0.26) and depersonalisation (ß=0.19, 95% CI 0.10 to 0.28) and with increased emotional exhaustion mediated by negative work-to-home spillover (ß=0.09, 95% CI 0.04 to 0.13). Support from direct supervisors mitigates the association between moral distress and emotional exhaustion (ß=0.16, 95% CI 0.04 to 0.27). CONCLUSIONS: Understanding moral distress as a root cause of burnout is too simplified. There is an important interplay between moral distress and work-home imbalance. Interventions that support individual coping with moral distress and a work-home imbalance, and the support of direct supervisors, are paramount to prevent burnout in physicians and nurses.

Mental well-being of intensive care unit nurses after the second surge of the COVID-19 pandemic: A cross-sectional and longitudinal study.

OBJECTIVES: To determine the impact of the second surge of the COVID-19 pandemic (October 2020 to June 2021) on mental well-being of intensive care unit nurses and factors associated with mental health outcomes. METHODS: An online survey was available for Dutch intensive care unit nurses in October 2021, measuring mental health symptoms; anxiety, depression (Hospital Anxiety and Depression Scale), and post-traumatic stress disorder (Impact of Event Scale-6). Additionally, work-related fatigue was measured using the Need For Recovery-11 questionnaire. Previous data from the first surge (March until June 2020) were used to study mental well-being longitudinally in a subgroup of intensive care unit nurses. Logistic regression analyses were performed to determine factors associated with mental health symptoms. RESULTS: In total, 589 nurses (mean age 44.8 [SD, 11.9], 430 [73.8 %] females) participated, of whom 164 also completed the questionnaire in 2020. After the second surge, 225/589 (38.2 %) nurses experienced one or more mental health symptoms and 294/589 (49.9 %) experienced work-related fatigue. Compared to the first measurement, the occurrence of mental health symptoms remained high (55/164 [33.5 %] vs 63/164 [38.4 %], p = 0.36) and work-related fatigue was significantly higher (66/164 [40.2 %] vs 83/164 [50.6 %], p = 0.02). Granted holidays as requested (aOR, 0.54; 95 % CI, 0.37-0.79), being more confident about the future (aOR, 0.59; 95 % CI, 0.37-0.93) and a better perceived work-life balance (aOR, 0.42; 95 % CI, 0.27-0.65) were significantly associated with less symptoms. CONCLUSION: The second surge of the COVID-19 pandemic further drained the mental reserves of intensive care unit nurses, resulting in more work-related fatigue.