Implementation of a digital diary in the intensive care unit; understanding the facilitators and barriers: A qualitative exploration.

BACKGROUND: In the recent years, digital intensive care unit (ICU) diaries have emerged as more advantageous than paper diaries. Despite the advantages of digital diaries, the successful implementation and maintenance of this digital intervention present significant challenges in clinical practice. Therefore, understanding the facilitators and barriers among stakeholders influencing this process becomes imperative for devising a tailored strategy to integrate digital diaries effectively within ICU settings. AIM/OBJECTIVE: The aim of this study was to explore facilitators and barriers for implementation of a digital ICU diary from the perspectives of ICU professionals, ICU survivors, and their relatives. METHODS: A qualitative design was used, incorporating focus-group interviews with professionals from four Dutch ICUs, along with individual interviews with ICU survivors and relatives. The study spanned from October 2022 to April 2023. Data analysis utilised a mixed inductive-deductive approach, particularly through directed content analysis. The Consolidated Framework for Implementation Research 2.0 guided both data collection and analysis processes. FINDINGS: We conducted five focus-group interviews among ICU professionals (n = 32) and 10 individual or dual interviews involving five ICU survivors and nine relatives. Key facilitators for implementing a digital diary according to ICU professionals encompassed a user-friendly interface accessible independent of time and place, with a seamless login process requiring minimal steps, comprehensive training covering all aspects of its use, and feedback from the experiences of both patients and relatives. Barriers for ICU professionals included many steps required to access the digital diary, as well as resistance to (co)writing diary entries. In contrast, professionals' involvement in writing diary entries was highly appreciated among ICU survivors and relatives. An ambiguous factor arose regarding sharing the digital diary with others; both ICU survivors and relatives found it valuable, yet it also raised privacy concerns. CONCLUSIONS: This study offers insights into the most important factors influencing the implementation of a digital ICU diary. Strikingly, some factors serve as both barriers and facilitators. When developing the implementation strategy, the identified facilitators can be used to overcome the barriers faced by ICU professionals, ICU survivors, and their relatives in adopting a digital diary.

Opinions and priorities for an e-health platform: A member consultation from an intensive care patient organisation.

BACKGROUND: To prevent deterioration after admission to the intensive care unit (ICU), and to improve rehabilitation, the ICU team should use digital technologies to provide comprehensive and practical information alongside personalised support for survivors and their family members. However, a knowledge gap exists on the users' preferences for such an e-health platform in ICU follow-up services. OBJECTIVES: This study aims to explore the opinions and priorities for an e-health platform, including choices in digital elements, according to survivors of critical illness and their family members. METHODS: A cross-sectional survey was used among members and other interested individuals of the Dutch volunteer organisation 'Foundation Family- and Patient-Centred Intensive Care'. An investigator-developed questionnaire was disseminated through the newsletter and social media channels of the Foundation Family- and Patient-Centred Intensive Care. The results of this member consultation were analysed and reported as descriptive statistics on demographic variables and outcome measures in opinions and priorities of the participants. RESULTS: Most of the 227 participants were female (76%), aged 46-55 years (33%), and completed higher education (70%). The participants reported high confidence in advice delivered through an e-health platform (72%). They prioritised the provision of a guide including relevant professionals who may support them during their recovery when using an e-health platform. CONCLUSIONS: ICU survivors prioritised the provision of relevant professionals who may support them during their recovery when using an e-health platform; however, selection bias means the population studied is likely to be more digitally connected than the general ICU population. Digital solutions could cater to their information and support needs. For family members, the highest priority reported was receiving help in managing their emotional distress. The development of an e-health platform considering the opinions and priorities of this target group could contribute to a personalised recovery trajectory promoting self-management while including digital elements addressing relevant ICU follow-up services.

Experiences with and needs for aftercare following the death of a loved one in the ICU: a mixed-methods study among bereaved relatives.

BACKGROUND: Bereaved relatives of intensive care unit (ICU) patients are at increased risk of psychological complaints. Aftercare might help them cope with processing the ICU admission and their loved one's death. There is little (qualitative) evidence on how bereaved relatives experience aftercare. Also, the COVID-19 pandemic likely impacted aftercare provision. We aim to examine how many relatives in Dutch ICUs received aftercare before and during the pandemic and to qualitatively describe their experiences and needs regarding aftercare. METHODS: A mixed-methods study among relatives of patients who died in an ICU before or during the COVID-19 pandemic. Bereaved relatives in six ICUs completed a questionnaire (n = 90), including two items on aftercare. These were analyzed using descriptive statistics and Chi-squared tests. Subsequently, both relatives that received and relatives that did not receive aftercare were interviewed about their experiences and needs regarding aftercare. The interviews were thematically analyzed. RESULTS: After the passing of a loved one, 44% of the relatives were asked by a healthcare professional from the hospital how they were doing, and 26% had had a follow-up conversation. Both happened more often during the first wave of the pandemic than during the second wave or before the pandemic. The most common reason for not having had a follow-up conversation was not knowing about this option (44%), followed by not feeling a need (26%). Regarding the latter, interviewed relatives explained that this would not revive their loved one or that they had already discussed everything they wanted. Relatives who wanted a follow-up conversation, wanted this because this would help them realize the severity of their loved one's illness, to exchange personal experiences, and/or to thank the ICU team. Those with a follow-up conversation said that they had reviewed the medical course of the admission and/or discussed their (mental) well-being. CONCLUSIONS: ICU healthcare professionals may play a vital role in addressing aftercare needs by asking relatives how they are doing in the weeks following the death of their loved one and offering them a follow-up conversation with an ICU physician. We recommend to include aftercare for bereaved relatives in ICU guidelines.

Varying (preferred) levels of involvement in treatment decision-making in the intensive care unit before and during the COVID-19 pandemic: a mixed-methods study among relatives.

BACKGROUND: In the intensive care unit (ICU) relatives play a crucial role as surrogate decision-makers, since most patients cannot communicate due to their illness and treatment. Their level of involvement in decision-making can affect their psychological well-being. During the COVID-19 pandemic, relatives' involvement probably changed. We aim to investigate relatives' involvement in decision-making in the ICU before and during the pandemic and their experiences and preferences in this regard. METHODS: A mixed-methods study among relatives of ICU patients admitted to an ICU before or during the COVID-19 pandemic. Relatives in six ICUs completed a questionnaire (n = 329), including two items on decision-making. These were analysed using descriptive statistics and logistic regression analyses. Subsequently, relatives (n = 24) were interviewed about their experiences and preferences regarding decision-making. Thematic analysis was used for analysing the qualitative data. RESULTS: Nearly 55% of the relatives indicated they were at least occasionally asked to be involved in important treatment decisions and of these relatives 97.1% reported to have had enough time to discuss questions and concerns when important decisions were to be made. During the first COVID-19 wave relatives were significantly less likely to be involved in decision-making compared to relatives from pre-COVID-19. The interviews showed that involvement varied from being informed about an already made decision to deliberation about the best treatment option. Preferences for involvement also varied, with some relatives preferring no involvement due to a perceived lack of expertise and others preferring an active role as the patient's advocate. Discussing a patient's quality of life was appreciated by relatives, and according to relatives healthcare professionals also found this valuable. In some cases the preferred and actual involvement was in discordance, preferring either a larger or a smaller role. CONCLUSIONS: As treatment alignment with a patient's values and preferences and accordance between preferred and actual involvement in decision-making is very important, we suggest that the treatment decision-making process should start with discussions about a patient's quality of life, followed by tailoring the process to relatives' preferences as much as possible. Healthcare professionals should be aware of relatives' heterogeneous and possibly changing preferences regarding the decision-making process.

A study protocol to develop and test an e-health intervention in follow-up service for intensive care survivors' relatives.

BACKGROUND: The negative impact on long-term health-related outcomes among relatives of critically ill patients in the intensive care unit (ICU) has been well described. High-quality ICU specialized follow-up care, which is easily accessible with digital innovation and which is designed by and with relevant stakeholders (i.e., ICU patients' relatives and nurses), should be considered to reduce these impairments in the psychological and social domains. AIM: The programme's aim is to develop and test an e-health intervention in a follow-up service to support ICU patients' relatives. Here, the protocol for the overall study programme will be described. STUDY DESIGN: The overall study comprises a mixed-methods, multicentre research design with qualitative and quantitative study parts. The study population is ICU patients' adult relatives and ICU nurses. The main outcomes are the experiences of these stakeholders with the newly developed e-health intervention. There will be no predefined selection based on age, gender, and level of education to maximize diversity throughout the study programme. After the participants provide informed consent, data will be gathered through focus groups (n = 5) among relatives and individual interviews (n = 20) among nurses exploring the needs and priorities of a digital follow-up service. The findings will be explored further for priority considerations among members of the patient/relative organization (aiming n = 150), which will serve as a basis for digital prototypes of the e-health intervention. Assessment of the intervention will be followed during an iterative process with investigator-developed questionnaires. Finally, symptoms of anxiety and depression will be measured with the 14-item Dutch version of the 'Hospital Anxiety and Depression Scale', and symptoms of posttraumatic stress will be measured with the 21-item Dutch version of the 'Impact of Events Scale-Revised' to indicate the effectiveness of digital support among ICU patients' relatives. RELEVANCE TO CLINICAL PRACTICE: The e-health intervention to be developed during this research programme can possibly bridge the gap in integrated ICU follow-up care by providing relevant information, self-monitoring and stimulating self-care among ICU patients' relatives.

The usability of a digital diary from the perspectives of intensive care patients' relatives: A pilot study.

BACKGROUND: Diaries have been used regularly in international settings as an evidence-based and easily applicable intervention following a person-centred approach in the intensive care unit (ICU). In addition, a diary web application known as 'Post-ICU' has been implemented. AIM: To explore the usability of an innovative digital diary from the perspectives of intensive care patients' relatives. STUDY DESIGN: A cross-sectional online survey study was applied among a convenience sample of relatives in the ICUs of two hospitals in the Netherlands. The investigator-developed questionnaire included, among other things, items with the appreciation of the layout, user friendliness and functionality of the diary. Relevance and applicability were rated between 1 and 10. Data were analysed with SPSS© software, version 27, and reported as the means (±standard deviation [SD]) and percentages. RESULTS: Sixty-three relatives with an average age of 51 years (SD ± 14.3) participated in the study; there was a slight predominance of women (57%). All but one participant found using the digital diary easy and were able to upload photos to the diary. The participants had invited other relatives (75%) and nurses (61%) to write in the diary, which they viewed as easily feasible (89%). The relevance and applicability of the diary were rated with mean scores of 8.1 (SD ± 1.9) and 8.3 (SD ± 1.6), respectively. CONCLUSIONS: The participants found the Post-ICU diary web application highly valuable and easily feasible. Perceived ease of use, perceived usefulness and technophobia were not found to influence the usability of the digital diary. RELEVANCE TO CLINICAL PRACTICE: The implementation of this new digital tool supports a person-centred ICU policy because of its focus on the personal diary entries of the patient and the collaborative writing process featuring relatives and professionals.

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.

Ten areas for ICU clinicians to be aware of to help retain nurses in the ICU.

Shortage of nurses on the ICU is not a new phenomenon, but has been exacerbated by the COVID-19 pandemic. The underlying reasons are relatively well-recognized, and include excessive workload, moral distress, and perception of inappropriate care, leading to burnout and increased intent to leave, setting up a vicious circle whereby fewer nurses result in increased pressure and stress on those remaining. Nursing shortages impact patient care and quality-of-work life for all ICU staff and efforts should be made by management, nurse leaders, and ICU clinicians to understand and ameliorate the factors that lead nurses to leave. Here, we highlight 10 broad areas that ICU clinicians should be aware of that may improve quality of work-life and thus potentially help with critical care nurse retention.

The impact of the first COVID-19 surge on the mental well-being of ICU nurses: A nationwide survey study.

OBJECTIVES: To determine the impact of the first COVID-19 surge (March through June 2020) on mental well-being and associated risk factors among intensive care unit nurses. RESEARCH METHODOLOGY: In September 2020, a nationwide cross-sectional survey study among Dutch intensive care nurses was carried out to measure prevalence rates of symptoms of anxiety, depression, posttraumatic stress disorder, and need for recovery (NFR), objectified by the HADS-A, HADS-D, IES-6 and NFR questionnaires, respectively. Associated risk factors were determined using multivariate logistic regression analyses. RESULTS: Symptoms of anxiety, depression, and post traumatic stress disorder were reported by 27.0%, 18.6% and 22.2% of the 726 respondents, respectively. The NFR was positive, meaning not being recovered from work, in 41.7%. Working in an academic hospital, being afraid of infecting relatives and experiencing insufficient numbers of colleagues were associated with more mental symptoms, while having been on holiday was associated with reduced depression symptoms and need for recovery. CONCLUSION: The first COVID-19 surge had a high impact on the mental well-being of intensive care nurses, increasing the risk for drop out and jeopardising the continuity of care. Effort should be made to optimize working conditions and decrease workload to guarantee care in the next months of the COVID-19 pandemic.

Burnout, resilience and work engagement among Dutch intensivists in the aftermath of the COVID-19 crisis: A nationwide survey.

PURPOSE: The COVID-19 crisis put a strain on intensive care resources everywhere in the world increasing the risk of burnout. Previously, the prevalence of burnout among Dutch intensivists was found to be low. Engagement and resilience among intensivists have not previously been studied quantitatively, however, both are related to burnout and provide a possible way to mitigate burnout. Our objective was to study burnout and its association with work engagement and resilience among Dutch intensivists in the aftermath of the COVID-19 crisis. METHODS: An online questionnaire was sent to all Dutch intensivists. The questionnaire consisted of questions on personal and work-related characteristics and validated questionnaires: the Maslach Burnout Inventory, the Utrecht Work Engagement Scale, and the Resilience Evaluation Scale. RESULTS: The response rate was 27.2% with 162 evaluable responses. Thirteen respondents (8.0%) were classified as having burnout, 63 (38.9%) respondents were reporting high work engagement. Burnout was found to be negatively associated with both work engagement and resilience. CONCLUSION: In the aftermath of the 2020 COVID-19 crisis, we found a raised prevalence of burnout among intensivists, however this is still low in international comparisons. Intensivists with burnout scored low on resilience and low on work engagement.

Perspectives of patients, relatives and nurses on rooming-in for adult patients: A scoping review of the literature.

AIM: To explore the perspectives of patients, their relatives and nurses on rooming-in for adult patients. BACKGROUND: The practice of having family stay overnight with an adult patient in hospital is quite new. To support rooming-in programs, the perspectives from all stakeholders should be taken into account. METHODS: All types of studies on rooming-in in adult healthcare settings were included in this scoping review. Rooming-in has been defined as the practice where 'family members or trusted others are facilitated to continuously stay with the patient and are provided with facilities to sleep in the patient's room'. RESULTS: Seven studies were included: one randomized controlled trial, three qualitative studies, and three correspondence articles. Generally, patients felt safe in the presence of a family member, but could also feel restricted in their freedom and privacy. Family members saw a benefit for the patient, considered rooming-in a moral duty, and were happy to help. Nonetheless, family members reported rooming-in as physically and emotionally stressful. Nurses described that patients were less anxious and more easily adjusted to the hospital environment. CONCLUSIONS: The reviewed studies suggest that patients, family members, and nurses have both positive and negative experiences with rooming-in. The concept of rooming-in varies from continuous presence and involvement of relatives to one overnight stay in the patient's room. Each interpretation has its own implications for policy, design, guidelines and feasibility of rooming-in. Nursing staff should be included in decision-making processes for this practice.

Developing and testing a nurse-led intervention to support bereavement in relatives in the intensive care (BRIC study): a protocol of a pre-post intervention study.

BACKGROUND: When a patient is approaching death in the intensive care unit (ICU), patients' relatives must make a rapid transition from focusing on their beloved one's recovery to preparation for their unavoidable death. Bereaved relatives may develop complicated grief as a consequence of this burdensome situation; however, little is known about appropriate options in quality care supporting bereaved relatives and the prevalence and predictors of complicated grief in bereaved relatives of deceased ICU patients in the Netherlands. The aim of this study is to develop and implement a multicomponent bereavement support intervention for relatives of deceased ICU patients and to evaluate the effectiveness of this intervention on complicated grief, anxiety, depression and posttraumatic stress in bereaved relatives. METHODS: The study will use a cross-sectional pre-post design in a 38-bed ICU in a university hospital in the Netherlands. Cohort 1 includes all reported first and second contact persons of patients who died in the ICU in 2018, which will serve as a pre-intervention baseline measurement. Based on existing policies, facilities and evidence-based practices, a nurse-led intervention will be developed and implemented during the study period. This intervention is expected to use 1) communication strategies, 2) materials to make a keepsake, and 3) a nurse-led follow-up service. Cohort 2, including all bereaved relatives in the ICU from October 2019 until March 2020, will serve as a post-intervention follow-up measurement. Both cohorts will be performed in study samples of 200 relatives per group, all participants will be invited to complete questionnaires measuring complicated grief, anxiety, depression and posttraumatic stress. Differences between the baseline and follow-up measurements will be calculated and adjusted using regression analyses. Exploratory subgroup analyses (e.g., gender, ethnicity, risk profiles, relationship with patient, length of stay) and exploratory dose response analyses will be conducted. DISCUSSION: The newly developed intervention has the potential to improve the bereavement process of the relatives of deceased ICU patients. Therefore, symptoms of grief and mental health problems such as depression, anxiety and posttraumatic stress, might decrease. TRIAL REGISTRATION: Netherlands Trial Register Registered on 27/07/2019 as NL 7875, www.trialregister.nl.

Framework to Support the Process of Decision-Making on Life-Sustaining Treatments in the ICU: Results of a Delphi Study.

OBJECTIVES: To develop a consensus framework that can guide the process of decision-making on continuing or limiting life-sustaining treatments in ICU patients, using evidence-based items, supported by caregivers, patients, and surrogate decision makers from multiple countries. DESIGN: A three-round web-based international Delphi consensus study with a priori consensus definition was conducted with experts from 13 countries. Participants reviewed items of the decision-making process on a seven-point Likert scale or with open-ended questions. Questions concerned terminology, content, and timing of decision-making steps. The summarized results (including mean scores) and expert suggestions were presented in the subsequent round for review. SETTING: Web-based surveys of international participants representing ICU physicians, nurses, former ICU patients, and surrogate decision makers. PATIENTS: Not applicable. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: In three rounds, respectively, 28, 28, and 27 (of 33 invited) physicians together with 12, 10, and seven (of 19 invited) nurses participated. Patients and surrogates were involved in round one and 12 of 27 responded. Caregivers were mostly working in university affiliated hospitals in Northern Europe. During the Delphi process, most items were modified in order to reach consensus. Seven items lacked consensus after three rounds. The final consensus framework comprises the content and timing of four elements; three elements focused on caregiver-surrogate communication (admission meeting, follow-up meeting, goals-of-care meeting); and one element (weekly time-out meeting) focused on assessing preferences, prognosis, and proportionality of ICU treatment among professionals. CONCLUSIONS: Physicians, nurses, patients, and surrogates generated a consensus-based framework to guide the process of decision-making on continuing or limiting life-sustaining treatments in the ICU. Early, frequent, and scheduled family meetings combined with a repeated multidisciplinary time-out meeting may support decisions in relation to patient preferences, prognosis, and proportionality.

Counterbalancing work-related stress? Work engagement among intensive care professionals.

BACKGROUND AND OBJECTIVES: Working in an Intensive Care Unit (ICU) is increasingly complex and is also physically, cognitively and emotionally demanding. Although the negative emotions of work-related stress have been well studied, the opposite perspective of work engagement might also provide valuable insight into how these emotional demands may be countered. This study focused on the work engagement of ICU professionals and explored the complex relationship between work engagement, job demands and advantageous personal resources. METHODS: This was a cross-sectional survey study among ICU professionals in a single-centre university hospital. Work engagement was measured by the Utrecht Work Engagement Scale, which included items about opinions related to the respondent's work environment. Additionally, 14 items based on the Jefferson Scale of Physician Empathy were included to measure empathic ability. A digital link to the questionnaire was sent in October 2015 to a population of 262 ICU nurses and 53 intensivists. RESULTS: The overall response rate was 61% (n=193). Work engagement was negatively related both to cognitive demands among intensivists and to emotional demands among ICU nurses. No significant relationship was found between work engagement and empathic ability; however, agreeableness, conscientiousness, and emotional stability were highly correlated with work engagement. Only the number of hours worked per week remained as a confounding factor, with a negative effect of workload on work engagement after controlling for the effect of weekly working hours. CONCLUSION: Work engagement counterbalances work-related stress reactions. The relatively high workload in ICUs, coupled with an especially heavy emotional burden, may be acknowledged as an integral part of ICU work. This workload does not affect the level of work engagement, which was high for both intensivists and nurses despite the known high job demands. Specific factors that contribute to a healthy and successful work life among ICU professionals need further exploration.

The Prevalence of Compassion Fatigue and Burnout among Healthcare Professionals in Intensive Care Units: A Systematic Review.

BACKGROUND: Working in the stressful environment of the Intensive Care Unit (ICU) is an emotionally charged challenge that might affect the emotional stability of medical staff. The quality of care for ICU patients and their relatives might be threatened through long-term absenteeism or a brain and skill drain if the healthcare professionals leave their jobs prematurely in order to preserve their own health. PURPOSE: The purpose of this review is to evaluate the literature related to emotional distress among healthcare professionals in the ICU, with an emphasis on the prevalence of burnout and compassion fatigue and the available preventive strategies. METHODS: A systematic literature review was conducted, using Embase, Medline OvidSP, Cinahl, Web-of-science, PsychINFO, PubMed publisher, Cochrane and Google Scholar for articles published between 1992 and June, 2014. Studies reporting the prevalence of burnout, compassion fatigue, secondary traumatic stress and vicarious trauma in ICU healthcare professionals were included, as well as related intervention studies. RESULTS: Forty of the 1623 identified publications, which included 14,770 respondents, met the selection criteria. Two studies reported the prevalence of compassion fatigue as 7.3% and 40%; five studies described the prevalence of secondary traumatic stress ranging from 0% to 38.5%. The reported prevalence of burnout in the ICU varied from 0% to 70.1%. A wide range of intervention strategies emerged from the recent literature search, such as different intensivist work schedules, educational programs on coping with emotional distress, improving communication skills, and relaxation methods. CONCLUSIONS: The true prevalence of burnout, compassion fatigue, secondary traumatic stress and vicarious trauma in ICU healthcare professionals remains open for discussion. A thorough exploration of emotional distress in relation to communication skills, ethical rounds, and mindfulness might provide an appropriate starting point for the development of further preventive strategies.

Relatives' perspectives on the quality of care in an Intensive Care Unit: the theoretical concept of a new tool.

OBJECTIVE: To examine the potential of a questionnaire (CQI 'R-ICU') to measure the quality of care from the perspective of relatives in the Intensive Care Unit (ICU). METHODS: A quantitative survey study has been undertaken to explore the psychometric properties of the instrument, which was sent to 282 relatives of ICU patients from the Erasmus MC, an academic hospital in Rotterdam, the Netherlands. Factor-analyses were performed to explore the underlying theoretical structure. RESULTS: Survey data from 211 relatives (response rate 78%) were used for the analysis. The overall reliability of the questionnaire was sufficiently high; two of the four underlying factors, namely 'Communication' and 'Involvement', were significant predictors. Two specific aspects of care that needed the most improvement were missing information about meals and offering an ICU diary. There is a significant difference in mean communication with nurses among the four wards in Erasmus MC. CONCLUSIONS: The CQI 'R-ICU' seems to be a valid, reliable and usable instrument. The theoretical fundament appears to be related to communication. PRACTICE IMPLICATIONS: The newly developed instrument can be used to provide feedback to health care professionals and policy makers in order to evaluate quality improvement projects with regard to relatives in the ICU.