Facilitating communication for critically ill patients and their family members: Study protocol for two randomized trials implemented in the U.S. and France

Perspectives on Implementing a Communication Facilitator Intervention From a Critical Care Setting

CONTEXT

Critically-ill patients and their families often experience communication challenges during their ICU stay and across care transitions. An intervention using communication facilitators may help address these challenges.

OBJECTIVES

Using clinicians' perspectives, we identified facilitators and barriers to implementing a communication intervention.

METHODS

Using purposive sampling, we conducted semi-structured interviews with 17 clinicians from an intensive care unit at an academic health center that participated in a randomized trial of communication facilitators. We used the Consolidated Framework for Implementation Research (CFIR) to guide data collection and analysis.

RESULTS

CFIR constructs of relative advantage, communication, and critical incidents facilitated the intervention's implementation. CFIR constructs of access to knowledge and information, relational connections, and clinician knowledge and belief hindered its implementation. Clinicians reported that facilitators provided continuity to patients and families, support in a trusting and proactive manner over transitions of care, and bridged communication between families and clinicians particularly during the Covid-19 pandemic. Limited information about the intervention prevented clinicians from working with facilitators earlier in the course of the intervention. Differences in beliefs regarding facilitator involvement during family meetings also hampered the intervention's implementation.

CONCLUSIONS

Future studies should incorporate implementation strategies that help connect facilitators to clinicians early in the intervention period which may improve role clarity and enhance collaboration.

Time to Talk Money? Intensive Care Unit Clinicians' Perspectives on Addressing Patients' Financial Hardship

BACKGROUND

Critically ill patients and their families commonly experience financial hardship, yet this experience is inadequately addressed by clinicians providing care in the intensive care unit. Understanding clinicians' perspectives on the barriers to addressing financial hardship provides an opportunity to identify and mitigate those barriers and improve patient outcomes.

OBJECTIVE

To characterize intensive care unit clinicians' experiences with and perceived barriers to addressing financial hardship with their patients.

METHODS

The study entailed a thematic analysis of semistructured interviews of 17 physicians, nurses, and social workers providing care to critically ill patients in a large academic health care system in the US Pacific Northwest.

RESULTS

Participants recognized the importance of addressing financial hardship as an integral part of patient-centered care but identified barriers influencing their comfort with and capacity to address financial hardship. Barriers fit into 2 themes: "(dis)comfort addressing financial hardship" and "values-based concerns." (Dis)comfort addressing financial hardship was influenced by systems- and practice-based barriers. Participants discussed concerns about real and perceived conflicts of interest when patient, family, clinician, and institutional priorities were not aligned.

CONCLUSIONS

Participants recognized financial hardship as an important consequence of critical illness that negatively affected patient and family outcomes, yet they described barriers to adequately addressing this topic. Normalizing discussions about the financial impacts of critical illness and systematically screening for financial hardship may be a first step in mitigating these barriers.

Communication needs regarding heart failure trajectory and palliative care between patients and healthcare providers: A cross-sectional study

INTRODUCTION

Heart failure (HF) is a chronic condition with an unpredictable trajectory, making effective communication between patients and healthcare providers crucial for optimizing outcomes. This study aims to investigate and compare the communication needs regarding HF trajectory and palliative care between patients and healthcare providers and to identify factors associated with the communication needs of patients with HF.

METHODS

A cross-sectional study design was employed, involving 100 patients with HF and 35 healthcare providers. Data were collected using structured questionnaires assessing communication needs, health literacy, self-care behavior, and social support. Statistical analyses were performed, including Spearman's rank correlation, Pearson's correlation, and multiple regression analyses.

RESULTS

Patients prioritized communication related to device-related questions, whereas healthcare providers focused more on aspects of HF in daily life. Both groups ranked end-of-life communication as the lowest priority. The communication needs of patients were positively correlated with health literacy (r = 0.27, p = .007), self-care behavior (r = 0.32, p = .001), and social support (r = 0.24, p = .016). Multiple regression analyses indicated that self-care behavior was a significant factor influencing the communication needs of patients (β = 0.27, p = .011).

CONCLUSIONS

Enhanced patient-centered communication strategies are required to address the communication priority gaps between patients and healthcare providers. Improving health literacy, supporting self-care behaviors, and leveraging social support are critical in meeting patients' communication needs. Tailored communication training for healthcare providers can bridge this gap and improve overall HF management.

Financial Hardship: A Qualitative Study Exploring Perspectives of Seriously Ill Patients and Their Family

CONTEXT

Seriously ill patients, such as those who experience critical illness, and their families experience a variety of poor outcomes, including financial hardship. However, little is known about the ways in which these seriously ill patients and their families experience financial hardship.

OBJECTIVE

To examine seriously ill patients' and families' experiences of financial hardship and perspectives on addressing these concerns during and after critical illness.

METHODS

We conducted a thematic analysis of semi-structured interviews with seriously ill patients who recently experienced a critical care hospitalization (n=15) and family caregivers of these patients (n=18).

RESULTS

Our analysis revealed three themes: 1) Prioritizing Survival and Recovery; 2) Living with Uncertainty-including experiences of prolonged uncertainty, navigating bureaucratic barriers, and long-term worries; and 3) Preferences for Financial Guidance. Our results suggest patients and families prioritize survival over financial hardship initially, and feelings of uncertainty about finances persist. However, patients and family caregivers are reluctant to have their physicians address financial hardship.

CONCLUSIONS

Our findings suggest that the acute and time sensitive nature of treatment decisions in critical care settings provides a unique context for experiences of financial hardship. Additional research is needed to better understand these experiences and design context-sensitive interventions to mitigate financial hardship and associated poor patient- and family-centered outcomes.

Exploring Implementation Processes of a Multicomponent Family Support Intervention in Intensive Care Units (FICUS) Study: A Mixed-Methods Process Evaluation

AIM

To investigate the experience with and progress of the implementation of a Family Support Intervention (FSI) into adult intensive care units (ICUs) as part of the cluster-randomised FICUS trial.

DESIGN

A mixed-methods process evaluation using a multiple case study approach guided by the normalisation process theory.

METHODS

This study took place between June 2022 and July 2023 in eight Swiss ICUs randomised to the intervention arm. A tailored implementation strategy was used to introduce the multicomponent FSI, consisting of a new family nursing role and a family care pathway, into interprofessional ICU teams. Participants were 40 ICU key clinical partners. Qualitative data were collected twice, early (3-6 months) and mid-implementation (9-12 months), using small group interviews. A questionnaire with psychometric measures (Acceptability of Intervention Measure, Feasibility of Intervention Measure, Intervention Appropriateness Measure, Normalisation Measure Development Questionnaire) was administered at mid-implementation. RITA pragmatic rapid thematic analysis and descriptive statistics were used to analyse the data. Qualitative and quantitative results were then compared across ICUs (cases).

FINDINGS

Findings indicated the desired progress of the FSI integration overall and across cases, with high acceptability and appropriateness ratings but only moderate to high feasibility scores. Study-related barriers were noted in all ICUs (i.e., FSI delivery as part of a clinical trial). Implementation barriers included family nurses' limited capacity and clinician's attitudes towards the FSI. Leadership support and interprofessional collaboration were identified as facilitators. Case-based, integrated findings yielded two implementation pathways, namely early and protracted adopters.

CONCLUSION

Implementation barriers were related to the feasibility of FSI delivery within the study context that required a high degree of standardisation and protocol adherence. Implementation progress was shaped by an interprofessional culture of family care, sufficient staff and time resources, and leadership support. The study's findings will inform future implementation of complex health interventions in ICUs.

REPORTING METHOD

Good reporting of a Mixed-Methods Study (GRAMMS).

PATIENT OR PUBLIC CONTRIBUTION

Within the FICUS trial, a patient and family advisory board with a patient expert, three family members and a patient with own lived experience of critical care collaborate with the research team.

"It's all about setting the stage." The nurse facilitator trial: perceived outcomes and implementation issues. A qualitative study among ICU clinicians and nurse facilitators

PURPOSE

For the first time in France, a randomised controlled trial was conducted to evaluate the impact of a nurse facilitator on family psychological symptoms. We sought to explore the implementation of the intervention, how it was experienced by clinicians, as well as the barriers and facilitators to implementing the change.

METHODS

We conducted qualitative semi-structured interviews with intensive care unit (ICU) clinicians and facilitators involved in the trial. Interview questions focused on participants' perceptions of the intervention and its outcomes, including the effect of the intervention on patients, families and the health care team, and barriers and facilitators to its implementation. Interviews were conducted by two social science researchers, audio recorded, transcribed, and analyzed using thematic content analysis.

RESULTS

Twenty-three clinicians were interviewed from the five participating ICUs. Three themes emerged, capturing clinicians' perspectives on implementing the intervention: (1) improved communication and enhanced care for families and the ICU team, albeit with some associated risks; (2) active listening and support, both for families and ICU clinicians but with certain limitations; (3) barriers to implementation including lack of organizational readiness, exclusion of under-represented groups, and facilitator challenges including role ambiguity and the need for role support.

CONCLUSION

Participants believed the facilitator intervention potentially improved families' experience. However, they also highlighted emotional difficulties and tensions with some members of the participating teams, due to competing territories and ambiguous role definitions. Facilitators' failure to affect decision-making suggests their role in enhancing goal-concordant care was inadequate within the setting.

Barriers and Strategies to Effective Serious Illness Communication for Patients with End-Stage Liver Disease in the Intensive Care Setting

Background: Patients with end-stage liver disease (ESLD) often require Intensive Care Unit (ICU) admission during the disease trajectory, but aggressive medical treatment has not resulted in increased quality of life for patients or caregivers. Methods: This narrative review synthesizes relevant data thematically exploring the current state of serious illness communication in the ICU with identification of barriers and potential strategies to improve performance. We provide a conceptual model underscoring the importance of providing comprehensible disease and prognosis knowledge, eliciting patient values and aligning these values with available goals of care options through a series of discussions. Achieving effective serious illness communication supports the delivery of goal concordant care (care aligned with the patient's stated values) and improved quality of life. Results: General barriers to effective serious illness communication include lack of outpatient serious illness communication discussions; formalized provider training, literacy and culturally appropriate patient-directed serious illness communication tools; and unoptimized electronic health records. ESLD-specific barriers to effective serious illness communication include stigma, discussing the uncertainty of prognosis and provider discomfort with serious illness communication. Evidence-based strategies to address general barriers include using the Ask-Tell-Ask communication framework; clinician training to discuss patients' goals and expectations; PREPARE for Your Care literacy and culturally appropriate written and online tools for patients, caregivers, and clinicians; and standardization of documentation in the electronic health record. Evidence-based strategies to address ESLD-specific barriers include practicing with empathy; using the "Best-Case, Worst Case" prognostic framework; and developing interdisciplinary solutions in the ICU. Conclusion: Improving clinician training, providing patients and caregivers easy-to-understand communication tools, standardizing EHR documentation, and improving interdisciplinary communication, including palliative care, may increase goal concordant care and quality of life for critically ill patients with ESLD.

A randomised controlled trial of a nurse facilitator to promote communication for family members of critically ill patients

PURPOSE

Suboptimal communication with clinicians, fragmented care and failure to align with patients' preferences are determinants of post intensive care unit (ICU) burden in family members. Our aim was to evaluate the impact of a nurse facilitator on family psychological burden.

METHODS

We carried out a randomised controlled trial in five ICUs in France comparing standard communication by ICU clinicians to additional communication and support by nurse facilitators. We included patients > 18 years, with expected ICU length of stay > 2 days, chronic life-limiting illness, and their family members. Facilitators were trained to help families to secure care in line with patient's goals, beginning in ICU and continuing for 3 months. Assessments were made at baseline and 1, 3 and 6 months post-randomisation. Primary outcome was the evolution of family symptoms of depression over 6 months using a linear mixed effects model on the depression subscale of the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes included HADS-Anxiety, Impact of Event Scale-6, goal-concordant care and experience of serious illness (QUAL-E).

RESULTS

385 patients and family members were enrolled. Follow-up at 1-, 3- and 6-month was completed by 284 (74%), 264 (68.6%) and 260 (67.5%) family members respectively. The intervention was associated with significantly more formal meetings between the ICU team and the family (1 [1-3] vs 2 [1-4]; p < 0.001). There was no significant difference between the intervention and control groups in evolution of symptoms of depression over 6 months (p = 0.91), nor in symptoms of depression at 6 months [0.53 95% CI (- 0.48; 1.55)]. There were no significant differences in secondary outcomes.

CONCLUSION

This study does not support the use of facilitators for family members of ICU patients.

Tailored implementation of the FICUS multicomponent family support intervention in adult intensive care units: findings from a mixed methods contextual analysis

BACKGROUND

The Family in Intensive Care UnitS (FICUS) trial investigates the clinical effectiveness of a multicomponent, nurse-led interprofessional family support intervention (FSI) and explores its implementation in intensive care units (ICUs). The local context of each ICU strongly influences intervention performance in practice. To promote FSI uptake and to reduce variation in intervention delivery, we aimed to develop tailored implementation strategies.

METHODS

A mixed method contextual analysis guided by the Consolidated Framework for Implementation Research (CFIR) was performed from March to June 2022 on eight ICUs assigned to the intervention group. ICU key clinical partners were asked to complete a questionnaire on CFIR inner setting measures (i.e., organizational culture, resources, learning climate and leadership engagement) and the Organizational Readiness for Implementing Change (ORIC) scale prior to group interviews, which were held to discuss barriers and facilitators to FSI implementation. Descriptive analysis and pragmatic rapid thematic analysis were used. Then, tailored implementation strategies were developed for each ICU.

RESULTS

In total, 33 key clinical partners returned the questionnaire and 40 attended eight group interviews. Results showed a supportive environment, with CFIR inner setting and ORIC measures each rated above 3 (scale: 1 low-5 high value), with leadership engagement scoring highest (median 4.00, IQR 0.38). Interview data showed that the ICU teams were highly motivated and committed to implementing the FSI. They reported limited resources, new interprofessional information exchange, and role adoption of nurses as challenging.

CONCLUSION

We found that important pre-conditions for FSI implementation, such as leadership support, a supportive team culture, and a good learning climate were present. Some aspects, such as available resources, interprofessional collaboration and family nurses' role adoption were of concern and needed attention. An initial set of implementation strategies were relevant to all ICUs, but some additions and adaptation to local needs were required. Multi-component interventions are challenging to implement within complex systems, such as ICUs. This pragmatic, theory-guided, mixed methods contextual analysis demonstrated high readiness and commitment to FSI implementation in the context of a clinical trial and enabled the specification of a tailored, multifaceted implementation strategy.

Supporting families of patients who die in adult intensive care: A scoping review of interventions

BACKGROUND

Families who perceive themselves as prepared for an impending death experience reduced psychological burden during bereavement. Understanding which interventions promote death preparedness in families during end-of-life care in intensive care will inform future intervention development and may help limit the burden of psychological symptoms associated with bereavement.

AIM

To identify and characterise interventions that help prepare families for the possibility of death in intensive care, incorporating barriers to intervention implementation, outcome variables and instruments used.

DESIGN

Scoping review using Joanna Briggs methodology, prospectively registered and reported using relevant guidelines.

DATA SOURCES

A systematic search of six databases from 2007 to 2023 for randomised controlled trials evaluating interventions that prepared families of intensive care patients for the possibility of death. Citations were screened against the inclusion criteria and extracted by two reviewers independently.

RESULTS

Seven trials met eligibility criteria. Interventions were classified: decision support, psychoeducation, information provision. Psychoeducation involving physician-led family conference, emotional support and written information reduced symptoms of anxiety, depression, prolonged grief, and post-traumatic stress in families during bereavement. Anxiety, depression, and post-traumatic stress were assessed most frequently. Barriers and facilitators to intervention implementation were seldom reported.

CONCLUSION

This review provides a conceptual framework of interventions to prepare families for death in intensive care, while highlighting a gap in rigorously conducted empirical research in this area. Future research should focus on theoretically informed, family-clinician communication, and explore the benefits of integrating existing multidisciplinary palliative care guidelines to deliver family conference within intensive care.

IMPLICATIONS FOR CLINICAL PRACTICE

Intensive care clinicians should consider innovative communication strategies to build family-clinician connectedness in remote pandemic conditions. To prepare families for an impending death, mnemonic guided physician-led family conference and printed information could be implemented to prepare families for death, dying and bereavement. Mnemonic guided emotional support during dying and family conference after death may also assist families seeking closure.

Implementation of a multicomponent family support intervention in adult intensive care units: study protocol for an embedded mixed-methods multiple case study (FICUS implementation study)

BACKGROUND

The implementation of complex interventions is considered challenging, particularly in multi-site clinical trials and dynamic clinical settings. This study protocol is part of the family intensive care units (FICUS) hybrid effectiveness-implementation study. It aims to understand the integration of a multicomponent family support intervention in the real-world context of adult intensive care units (ICUs). Specifically, the study will assess implementation processes and outcomes of the study intervention, including fidelity, and will enable explanation of the clinical effectiveness outcomes of the trial.

METHODS AND ANALYSIS

This mixed-methods multiple case study is guided by two implementation theories, the Normalisation Process Theory and the Consolidated Framework for Implementation Research. Participants are key clinical partners and healthcare professionals of eight ICUs allocated to the intervention group of the FICUS trial in the German-speaking part of Switzerland. Data will be collected at four timepoints over the 18-month active implementation and delivery phase using qualitative (small group interviews, observation, focus group interviews) and quantitative data collection methods (surveys, logs). Descriptive statistics and parametric and non-parametric tests will be used according to data distribution to analyse within and between cluster differences, similarities and factors associated with fidelity and the level of integration over time. Qualitative data will be analysed using a pragmatic rapid analysis approach and content analysis.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Cantonal Ethics Committee of Zurich BASEC ID 2021-02300 (8 February 2022). Study findings will provide insights into implementation and its contribution to intervention outcomes, enabling understanding of the usefulness of applied implementation strategies and highlighting main barriers that need to be addressed for scaling the intervention to other healthcare contexts. Findings will be disseminated in peer-reviewed journals and conferences.

PROTOCOL REGISTRATION NUMBER

Open science framework (OSF) https://osf.io/8t2ud Registered on 21 December 2022.