Perceptions of Families of Intensive Care Unit Patients Regarding Involvement in Delirium-Prevention Activities: A Qualitative Study

ICU nurses' perceptions on family involvement in delirium care for postoperative cardiac surgery patients: A qualitative study

AIMS

Delirium is common among adults recovering from cardiac surgery in the intensive care unit (ICU), prompting increased family involvement in their care. This study aimed to describe ICU nurses' perceptions of factors that support or impede family involvement in preventing, assessing, and managing delirium in the postoperative period following cardiac surgery.

METHODS

A convenience sample of 18 nurses with a mean age 36 years (24-49), 89 % female) was recruited from two university-affiliated ICUs in Canada. After providing written informed consent, participants engaged in a semi-structured individual interview. Descriptive thematic analysis was performed using an established method.

FINDINGS

The analysis identified six key themes: 1) Choosing the right time to involve the family, 2) The importance of sharing information, 3) Influence of family characteristics, 4) Influence of organizational characteristics, 5) Family input helps detect delirium, and 6) Families can take concrete actions when delirium occurs. Notably, while information sharing during delirium episodes was highly valued, discussions on delirium prevention were absent among all nurse participants.

CONCLUSIONS

Overall, ICU nurses perceive family involvement in delirium care as beneficial, depending on factors such as patient condition, nurse attitudes and preferences, family characteristics, and organizational support. This qualitative study provides valuable insights on nurses' perceptions regarding family involvement in ICU settings.

IMPLICATIONS FOR CLINICAL PRACTICE

ICU nurses, healthcare administrators and educators can use these findings to support family involvement in ICU delirium care after cardiac surgery. Overcoming barriers, particularly around delirium prevention, requires further investigation into nurses' education, resource allocation, and organizational support.

Nurses' Experiences of the Quality of Family-Centered Patient Counselling in Paediatric Delirium: A Qualitative Descriptive Study

AIM

To describe nurses' experiences of the quality of family-centred patient counselling in paediatric delirium.

DESIGN

A qualitative descriptive study.

METHODS

Semi-structured interviews were conducted with 10 PICU nurses with experience in managing paediatric patients at high risk of developing delirium. The data were analysed inductively.

RESULTS

The study identified four main categories, 10 generic categories, and 34 specific subcategories within family-centered patient counselling in paediatric delirium, offering a comprehensive framework to enhance counselling practices for families in paediatric delirium care.

CONCLUSIONS

The study highlights areas to improve family-centered patient counselling in paediatric delirium, particularly focusing on sufficiency, resources, and implementation. It emphasises the need for improved delirium-related knowledge among healthcare providers. The study also suggests that digital services, such as websites and digital care pathways, can improve information access for families, enhancing the family-centeredness of counselling.

PATIENT OR PUBLIC CONTRIBUTION

None.

Identifying family experiences and perspectives on involvement in care of adult ICU patients under family-centered care: A systematic review of qualitative studies

AIMS

To synthesize the results of qualitative research on family involvement in the care of adult ICU patients under family-centered care, to understand their experiences and perspectives, and to analyze the influences and future requirements of this process.

METHODS

The search followed the Preferred Reporting Items for Systematic Review and Meta-Analysis report (PRISMA 2020). A comprehensive search of eight databases was conducted for qualitative research on family involvement in adult ICU care. The quality of studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist, and meta-aggregation methods were used to extract, categorize and synthesize data.

RESULTS

Ten studies were included, of which 69 findings were extracted, and similar results were categorized and grouped into 13 categories, resulting in four synthesized findings, including Purpose of family involvement, Factors influencing family involvement, Preferences for family involvement and Requirements for family involvement.

CONCLUSIONS

To provide a systematic family perspective on family-centered care by reviewing qualitative findings on family involvement in the care of adult ICU patients, understanding the purpose, preferences, and factors influencing family involvement, and identifying future requirements and directions for family involvement in the adult intensive care unit.

IMPLICATIONS FOR CLINICAL PRACTICE

This review emphasizes the importance and necessity of family involvement in ICU care, clarifies the attitudes, preferences and influencing factors from the family's perspective, suggests assessing their ability to participate and giving them free choices, strengthens guidance and education, and promotes the establishment of a good cooperative relationship between families and healthcare professionals. In addition, the external construction of ICU family involvement, including the environment and policies, should be actively improved.

Family Presence at the PICU Bedside and Pediatric Patient Delirium: Retrospective Analysis of a Single-Center Cohort, 2014-2017

OBJECTIVES

To examine the association between family presence at the PICU bedside and daily positive delirium screening scores.

DESIGN

Retrospective cohort study.

SETTING

Tertiary children's hospital PICU.

SUBJECTS

Children younger than 18 years old with PICU length of stay greater than 36 hours enrolled in the Seattle Children's Hospital Outcomes Assessment Program from 2014 to 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In the dataset, delirium screening had been performed bid using the Cornell Assessment of Pediatric Delirium, with scores greater than or equal to 9 classified as positive. Family presence was documented every 2 hours. Among 224 patients, 55% ( n = 124/224) had positive delirium screening on 44% ( n = 408/930) of PICU days. Family presence at the bedside during PICU stay (< 90% compared with ≥ 90%) was associated with higher proportion of ever (as opposed to never) being screened positive for delirium (26/37 vs. 98/187; difference, 17.9% [95% CI, 0.4-32.1%]; p = 0.046). On univariate analysis, each additional decile of increasing family presence was associated with lower odds of positive delirium screening on the same day (odds ratio [OR], 0.87 [95% CI, 0.77-0.97]) and subsequent day (OR, 0.84 [95% CI, 0.75-0.94]). On multivariable analysis after adjustments, including baseline Pediatric Cerebral Performance Category (PCPC), higher family presence was associated with lower odds of subsequent-day positive delirium screening (OR, 0.89 [95% CI, 0.81-0.98]). Among patients with PCPC less than or equal to 2, each additional decile of increasing family presence was independently associated with lower odds of both same-day (OR, 0.90 [95% CI, 0.81-0.99]) and subsequent-day (OR, 0.85 [95% CI, 0.76-0.95]) positive delirium screening.

CONCLUSIONS

In our 2014-2017 retrospective cohort, greater family presence was associated with lower odds of delirium in PICU patients. Family presence is a modifiable factor that may mitigate the burden of pediatric delirium, and future studies should explore barriers and facilitators of family presence in the PICU.

Delirium in the Acute Care Setting From the Families Perspective: A Scoping Review

AIM

To explore the existing literature on delirium within the acute care setting from the family members' perspective and summarise key findings.

DESIGN

A scoping review guided by Arksey and O'Malley's methodological framework and refined by the Joanna Briggs Institute.

REVIEW METHODS

The Population, Concept, and Context framework recommended by the Joanna Briggs Institute's scoping review protocol identified the main concepts in the primary review question. The inclusion criteria focused on primary research studies from any chronological date that explored the family members' experience of delirium within the acute care setting. Following screening by two independent reviewers, data extraction was conducted and presented in tabular form, detailing the study aim, sample, setting, methods, key findings and recommendations for future research and clinical practice.

DATA SOURCES

A comprehensive search was conducted in January 2025 using CINAHL+, MEDLINE, JBI, Cochrane Library, Web of Science, Scopus and Google Scholar. Citation searching and reference lists supplemented this review to identify relevant studies.

RESULTS

Seventeen studies met the inclusion criteria. Families' experiences of delirium were categorised into (1) lack of awareness and understanding of delirium; (2) communication and informational needs of family members regarding delirium; (3) the emotional impact delirium has on family members, and (4) family desire to participate in their loved one's care.

CONCLUSION

This review highlighted a paucity of literature addressing the experiences of family members who witness delirium in the acute care setting. The existing research underscored the need for clear communication and information regarding delirium to mitigate the negative emotional impact that delirium places on families.

IMPACT

This scoping review provides insights into the challenges facing families witnessing delirium in the acute care setting. A better understanding of family members' experiences can guide the development of a supported family-centred approach to delirium care.

PATIENT CONTRIBUTION

No patient/public contribution.

Nurses' Experiences of the Prerequisites for Implementing Family-Centered Care to Prevent Pediatric Delirium

PURPOSE

The aim of this study was to describe nurses' experiences of the prerequisites for implementing family-centered care to prevent pediatric delirium.

DESIGN

The research employed a qualitative, descriptive study design.

METHODS

A total of 10 nurses working in the pediatric intensive care unit at 1 university hospital participated in the study. The quality data were collected using individual semistructured interviews, and the data were then analyzed by inductive content analysis.

RESULTS

The prerequisites for implementing family-centered care to prevent delirium among pediatric patients consisted of 30 subcategories that were grouped into 11 generic categories. The generic categories were further grouped into 5 main categories: (1) an environment that supports family presence, (2) psychosocial support for the family, (3) individual family involvement, (4) family participation in shared decision-making, and (5) nurses' professional competence.

CONCLUSIONS

According to the nurses' experiences, the implementation of a family-centered approach to preventing delirium in pediatric patients requires creating a supportive environment for families, providing psychosocial support, encouraging family involvement in decision-making, and ensuring that all nurses have the necessary skills.

A Case Report and Review of the Literature of ICU Delirium

This case report focuses on what patients and family members may experience when a neurological trauma transpires and resultant intensive care (ICU) delirium occurs. It is the personal account of the patient (A.B.) and spouse's (R.G.B.) perspectives when the patient (A.B) suffered a vertebral artery aneurysm and hemorrhage and experienced intensive care unit (ICU) delirium after being in the ICU for 22 days. This case report provides the patient's and spouse's perspectives regarding delirium, i.e., A.B.'s inability to discern reality, loss of memory, paranoia and hallucinations, agency and recovery, post-ICU syndrome, and post-traumatic stress disorder (PTSD). Clinical diagnosis by the neurosurgeon indicated delirium, with treatment consisting of sleep sedation and uninterrupted sleep. A.B. was able to regain consciousness yet experienced post-traumatic stress disorder up to one year afterward. Consistent family participation in the patient's delirium care is crucial. Family member care and family-centered strategies are provided with implications for future research and health care.

Psychometric Evaluation of the Family Willingness for Caregiving Scale

BACKGROUND

Family members and close friends of patients undergoing mechanical ventilation in the intensive care unit (ICU) often experience stress and a sense of helplessness. Participating in the care of their loved one may improve their adaptation to the ICU environment and better prepare them for caregiving after discharge.

OBJECTIVES

The primary aim of this study was to develop the Family Willingness for Caregiving Scale (FWCS) and test its psychometric properties. The secondary aim was to examine relationships between family members' demographic characteristics and caregiving willingness.

METHODS

The process of scale development followed DeVellis's 8-step method, and the scale was tested in 3 phases. The first 2 phases examined content validity and face validity, respectively. In phase 3, the FWCS was administered to a sample of family members currently visiting an ICU patient.

RESULTS

Content validity and face validity were confirmed. The internal consistency reliability of the scale was acceptable, and exploratory factor analysis revealed a 1-factor structure comprising both physical and emotional/supportive care tasks. Caregiving willingness differed significantly by sex, with women reporting greater willingness than men reported.

CONCLUSIONS

Further testing of the FWCS is needed. After refinement, the FWCS could be used to evaluate factors contributing to caregiving willingness of family members of ICU patients and advance the science related to family engagement in the ICU. Additionally, it could be used as a practical tool to suggest family caregiving activities in the ICU.

Sources of Sound Exposure in Pediatric Critical Care

BACKGROUND

Sound levels in the pediatric intensive care unit (PICU) are often above recommended levels, but few researchers have identified the sound sources contributing to high levels.

OBJECTIVES

To identify sources of PICU sound exposure.

METHODS

This was a secondary analysis of continuous bedside video and dosimeter data (n = 220.7 hours). A reliable coding scheme developed to identify sound sources in the adult ICU was modified for pediatrics. Proportions of sound sources were compared between times of high (≥45 dB) and low (<45 dB) sound, during day (7 AM to 6:59 PM) and night (7 PM to 6:59 AM) shifts, and during sound peaks (≥70 dB).

RESULTS

Overall, family vocalizations (38% of observation time, n = 83.9 hours), clinician vocalizations (32%, n = 70.6 hours), and child nonverbal vocalizations (29.4%, n = 64.9 hours) were the main human sound sources. Media sounds (57.7%, n = 127.3 hours), general activity (40.7%, n = 89.8 hours), and medical equipment (31.3%, n = 69.1 hours) were the main environmental sound sources. Media sounds occurred in more than half of video hours. Child nonverbal (71.6%, n = 10.2 hours) and family vocalizations (63.2%, n = 9 hours) were highly prevalent during sound peaks. General activity (32.1%, n = 33.2 hours), clinician vocalizations (22.5%, n = 23.3 hours), and medical equipment sounds (20.6, n = 21.3 hours) were prevalent during night shifts.

CONCLUSIONS

Clinicians should partner with families to limit nighttime PICU noise pollution. Large-scale studies using this reliable coding scheme are needed to understand the PICU sound environment.

Understanding family carer experiences and perceptions of engagement in delirium prevention and care for adults in hospital: Qualitative systematic review

AIM

To identify, describe and synthesise what is known about family carers' experiences and perspectives of engagement in delirium prevention and care for adults in hospital.

DESIGN

Systematic review and synthesis of qualitative evidence.

DATA SOURCES

Comprehensive literature search within PubMed, CINAHL, EMBASE, Scopus, Cochrane Central and PsycInfo databases to August 2022. Peer reviewed original qualitative research published in English.

METHODS

Data were extracted using Covidence systematic review software. Methodological quality was reviewed against the Critical Appraisal Skills Program (CASP) Qualitative Checklist. Thematic synthesis was used to develop analytical themes. Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) framework was applied to findings.

RESULTS

Of 3429 records identified, 29 met criteria for final inclusion. Studies included a range of settings (intensive care, medical and surgical wards) and family carer types (spouse, daughter, parent and friend). Three primary themes Shared Caregiving, Partnership and Support, Communication for Shared Understanding and three cross-cutting contextual themes Care Transitions, Family Carer Context and Hospital Context were identified. Family carers have mixed experiences of involvement in delirium care and prevention. Family carer engagement in care impacted perceptions of care quality and their own self-efficacy. Where person-centred care expectations were not met, some family carers adopted compensatory or care contingency strategies. Information sharing and timely support from hospital staff who understood the carer context supported carer involvement. Supportive physical environments and addressing power imbalances allowed greater engagement.

CONCLUSION

Family carers often wish to be involved in delirium prevention and care, but need to be recognised as individuals, listened to, informed and supported to optimise their contribution.

IMPACT

The review findings can guide health professional and decision makers to optimise family carer involvement in delirium care programs.

PROTOCOL REGISTRATION

PROSPERO [CRD42020221854].

REPORTING

ENTREQ. No Patient or Public Contribution.

The Relationship Between Uncertainty and Psychological Distress Among Family Caregivers of Patients With Delirium in Intensive Care Units: A Cross-Sectional Survey

BACKGROUND

Although family caregivers experienced negative psychological symptoms associated with witnessing intensive care unit delirium in their loved ones, there is a lack of clear understanding of how delirium is associated with family caregiver psychological distress. Uncertainty could be a factor contributed to this association.

OBJECTIVES

The aim of this study was to examine the relationship between uncertainty and psychological distress among family caregivers of patients with delirium in intensive care units.

METHODS

A cross-sectional correlational design was used for this observational study of adult family caregivers of patients admitted to the intensive care unit and who reported witnessing delirium symptoms in their loved ones. Family caregivers completed an electronic survey in January 2022 that consisted of a family caregiver and patient demographic form, the Mishel Uncertainty in Illness Scale-Family Member, and the Kessler Psychological Distress Scale. Descriptive, correlational, and regression statistical analyses were applied.

RESULTS

One hundred twenty-one adult family caregivers were enrolled. Family caregivers reported substantial uncertainty (mean, 106.15, on a scale of 31-155) and moderate to severe psychological distress (mean, 31.37, on a scale of 10-50) regarding their witnessing of delirium episodes in their loved ones. Uncertainty was significantly correlated with psychological distress among family caregivers (rs = 0.52, P < .001). Uncertainty significantly predicted psychological distress among family caregivers (regression coefficient, 0.27; P < .001).

DISCUSSION

Family caregiver uncertainty was positively associated with psychological distress. This distress can interfere with family caregiver involvement in patient delirium care. These findings are essential to increase critical care nurse awareness and inform the development of nursing interventions to alleviate possible uncertainty and distress.

Physicians' beliefs and perceived importance of traumatic brain injury-associated agitation in critically ill patients: a survey of Canadian intensivists

PURPOSE

Agitation is a common behavioural problem following traumatic brain injury (TBI). Intensive care unit (ICU) physicians' perspectives regarding TBI-associated agitation are unknown. Our objective was to describe physicians' beliefs and perceived importance of TBI-associated agitation in critically ill patients.

METHODS

Following current standard guidance, we built an electronic, self-administrated, 42-item survey, pretested it for reliability and validity, and distributed it to 219 physicians working in 18 ICU level-1 trauma centres in Canada. We report the results using descriptive statistics.

RESULTS

The overall response rate was 93/219 (42%), and 76/93 (82%) respondents completed the full survey. Most respondents were men with ten or more years of experience. Respondents believed that pre-existing dementia (90%) and regular recreational drug use (86%) are risk factors for agitation. Concerning management, 91% believed that the use of physical restraints could worsen agitation, 90% believed that having family at the bedside reduces agitation, and 72% believed that alpha-2 adrenergic agonists are efficacious for managing TBI agitation. Variability was observed in beliefs on epidemiology, sex, gender, age, socioeconomic status, and other pharmacologic options. Respondents considered TBI agitation frequent enough to justify the implementation of management protocols (87%), perceived the current level of clinical evidence on TBI agitation management to be insufficient (84%), and expressed concerns about acute and long-term detrimental outcomes and burden to patients, health care professionals, and relatives (85%).

CONCLUSION

Traumatic brain injury-associated agitation in critically ill patients was perceived as an important issue for most ICU physicians. Physicians agreed on multiple approaches to manage TBI-associated agitation although agreement on epidemiology and risk factors was variable.

Experiences of relatives of patients with delirium due to an acute health event - A systematic review of qualitative studies

OBJECTIVE

Evaluate relatives' experience of delirium due to an acute health event in a loved person and to compile practical suggestions for health care professionals from these synthesized results.

BACKGROUND

Delirium resulting from an acute health event places patients at increased risk for prolonged hospitalization and mortality. A delirium episode also affects family members who may assist in the diagnosis and recovery from this condition.

INCLUSION CRITERIA

Qualitative studies of family members or other caregivers who witnessed patient delirium in a clinical setting were included if they had appropriate verbatim evidence. Studies dealing exclusively with delirium in the context of dementia, cancer, palliative care, or drug dependence were excluded, and if quotes could not be clearly allocated to relatives.

METHODS

A systematic review of qualitative studies adapted from the Joanna Briggs Institute meta-aggregation approach. A systematic literature search was conducted in CINAHL complete®, MEDLINE®, and several dissertation databases in September 2022.

RESULTS

Eight qualitative studies based on semi-structured interviews were included. In total 75 findings from 105 relatives were aggregated into 13 categories. Finally, three synthesized findings reveal suggestions for health care professionals: providing information adequately, communication and integration during health care and understanding relatives' perspective on delirium experience.

CONCLUSION

The identified burdens and needs of relatives should be considered by health care professionals to enhance the delirium experience for them, thus improving patient care by involving relatives with a better understanding.

Nonpulmonary Treatments for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

OBJECTIVES

To provide an updated review of the literature on nonpulmonary treatments for pediatric acute respiratory distress syndrome (PARDS) from the Second Pediatric Acute Lung Injury Consensus Conference.

DATA SOURCES

MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost).

STUDY SELECTION

Searches were limited to children with PARDS or hypoxic respiratory failure focused on nonpulmonary adjunctive therapies (sedation, delirium management, neuromuscular blockade, nutrition, fluid management, transfusion, sleep management, and rehabilitation).

DATA EXTRACTION

Title/abstract review, full-text review, and data extraction using a standardized data collection form.

DATA SYNTHESIS

The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Twenty-five studies were identified for full-text extraction. Five clinical practice recommendations were generated, related to neuromuscular blockade, nutrition, fluid management, and transfusion. Thirteen good practice statements were generated on the use of sedation, iatrogenic withdrawal syndrome, delirium, sleep management, rehabilitation, and additional information on neuromuscular blockade and nutrition. Three research statements were generated to promote further investigation in nonpulmonary therapies for PARDS.

CONCLUSIONS

These recommendations and statements about nonpulmonary treatments in PARDS are intended to promote optimization and consistency of care for patients with PARDS and identify areas of uncertainty requiring further investigation.

Family experiences and attitudes toward care of ICU patients with delirium: A scoping review

Introduction

The family has an important role in the care of the ICU patient. Research shows that the implementation of non-pharmacological interventions to prevent delirium, including interventions with the family, can reduce the incidence of delirium. The aim of this review was to search the available literature about the experiences and attitudes of family/carers of ICU patients diagnosed with delirium during hospitalization.

Methods

A scoping review method was used to map terms relevant to the involvement of relatives in the care of critically ill patients with delirium. To identify studies, the following databases were searched: PubMed, Scopus, EBSCO, Web of Science, and Cochrane Library. The database search was ongoing from 15 July 2022, with a final search on 4 August 2022.

Results

Thirteen articles reporting on the experiences and attitudes of family/carers of ICU patients who developed delirium during hospitalization were included in the scoping review. Of the included studies, eight were qualitative studies, three were quantitative studies and two were reviews (systematic review and integrative review). The studies were conducted in North America, Europe, South Africa, and Asia. Our findings show that carers experienced adverse effects associated with delirium in ICU patients such as stress, anxiety, embarrassment, uncertainty, anger, shock. Families/relatives need both emotional and informational support from medical staff.

Conclusion

Relatives want to be involved in the care of the delirium patient, although this needs improvement in some aspects of care such as: lack of awareness, family/relatives knowledge of delirium, improved education, and communication with medical staff. Recognition of delirium by families is acceptable and feasible. Family involvement may induce an increased anxiety, but this aspect needs further research.

Exploring perceptions regarding family-based delirium management in the intensive care unit

Background

Delirium is a common complication in patients treated in the intensive care unit (ICU). Family members can help alleviate patient anxiety and may be able to aid in the management of delirium. This study aimed to explore the perceptions of former ICU patients and their families together, regarding the involvement of family in delirium management.

Method

Nine audio-recorded, semi-structured interviews took place with former ICU patients together with a family member. Participants were interviewed after their intensive care follow-up clinic appointment in an East Midlands hospital in England. Interviews were transcribed, coded and analysed using thematic analysis.

Results

Three themes were identified: 'understanding about delirium'; 'influencers of delirium management: family and healthcare professionals' and 'family-based delirium care'. Participants expressed that family have a valuable role to play in the management of delirium in the ICU. However, education and guidance is needed to support the family in how delirium can be managed and the current treatment options available. It is important for ICU staff to gain an understanding of the patient's life and personality to personalise delirium management to the needs of the patient and their family.

Conclusion

This study found that family presence and knowledge about the patient may be beneficial to delirium management in the ICU. Further research should investigate the effectiveness of the strategies and interventions to understand their influence on delirium management in ICU patients.

Stakeholder perspectives of a pilot multicomponent delirium prevention intervention for adult patients with advanced cancer in palliative care units: A behaviour change theory-based qualitative study

BACKGROUND

Theory-based and qualitative evaluations in pilot trials of complex clinical interventions help to understand quantitative results, as well as inform the feasibility and design of subsequent effectiveness and implementation trials.

AIM

To explore patient, family, clinician and volunteer ('stakeholder') perspectives of the feasibility and acceptability of a multicomponent non-pharmacological delirium prevention intervention for adult patients with advanced cancer in four Australian palliative care units that participated in a phase II trial, the 'PRESERVE pilot study'.

DESIGN

A trial-embedded qualitative study via semi-structured interviews and directed content analysis using Michie's Behaviour Change Wheel and the Theoretical Domains Framework.

SETTING/PARTICIPANTS

Thirty-nine people involved in the trial: nurses (n = 17), physicians (n = 6), patients (n = 6), family caregivers (n = 4), physiotherapists (n = 3), a social worker, a pastoral care worker and a volunteer.

RESULTS

Participants' perspectives aligned with the 'capability', 'opportunity' and 'motivation' domains of the applied frameworks. Of seven themes, three were around the alignment of the delirium prevention intervention with palliative care (intervention was considered routine care; intervention aligned with the compassionate and collaborative culture of palliative care; and differing views of palliative care priorities influenced perspectives of the intervention) and four were about study processes more directly related to adherence to the intervention (shared knowledge increased engagement with the intervention; impact of the intervention checklist on attention, delivery and documentation of the delirium prevention strategies; clinical roles and responsibilities; and addressing environmental barriers to delirium prevention).

CONCLUSION

This theory-informed qualitative study identified multiple influences on the delivery and documentation of a pilot multicomponent non-pharmacological delirium prevention intervention in four palliative care units. Findings inform future definitive studies of delirium prevention in palliative care.Australian New Zealand Clinical Trials Registry, ACTRN12617001070325; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373168.

Non-pharmacological delirium prevention practices among critical care nurses: a qualitative study

Background

Delirium is common among critically ill patients, leading to increased mortality, physical dependence, and cognitive impairment. Evidence suggests non-pharmacological delirium prevention practices are effective in preventing delirium. However, only a few studies explore the actual implementation and its associated challenges among critical care nurses.

Aim

To explore critical care nurses’ perceptions of current non-pharmacological delirium prevention practices in adult intensive care settings, including delirium screening, early mobilisation, sleep promotion, family engagement, and sensory stimulation.

Methods

A qualitative design adopting a thematic analysis approach. Semi-structured interviews with 20 critical care nurses were conducted in ten acute hospitals in mainland China.

Results

Three themes emerged: (a) importance of family engagement; (b) influence of organisational factors, and (c) suggestions on implementation. The implementation of non-pharmacological delirium prevention practices was limited by a strict ICU visitation policy, lack of routine delirium screening and delirium training, light and noise disturbances during nighttime hours, frequent resuscitation and new admissions and strict visitation policy. Case-based training, adopting a sensory stimulation protocol, and family engagement may be enablers.

Conclusion

ICU care routine that lacks delirium assessment and the strict family visitation policy made it challenging to implement the complete bundle of non-pharmacological practices. Resource deficiency (understaffing, lack of training) and ICU environment (frequent resuscitation) also limited the implementation of non-pharmacological practices. Clinicians could implement case-based training and sensory-stimulation programs and improve communication with family caregivers by instructing family caregivers to recognise delirium symptoms and delirium prevention strategies.

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

BACKGROUND

Family participation in essential care activities may benefit both patients and relatives.

OBJECTIVES

In this integrative review, we aimed to identify needs, perceptions, preferences, and capacities regarding family participation in essential care in intensive care units (ICUs) from the patient's, relatives', and ICU healthcare providers' perspective.

REVIEW METHOD USED

An integrative review method was used.

DATA SOURCES

PubMed, CINAHL, EMBASE, MEDLINE, Cochrane, Web of Science, and reference lists of included articles were searched, from inception to January 25, 2021.

REVIEW METHODS

We included studies on family participation in essential care activities during ICU stay which reported associated needs, perceptions, preferences and capacities. Quality assessment was performed with the Kmet Standard Quality Assessment Criteria developed for evaluating primary research papers in a variety of fields, and an extensive qualitative thematic analysis was performed on the results.

RESULTS

Twenty-seven studies were included. Quality scores varied from 0.45 to 0.95 (range: 0-1). Patients' needs, perceptions, preferences, and capacities are largely unknown. Identified themes on needs and perceptions were relatives' desire to help the patient, a mostly positive attitude among all involved, stress regarding patient safety, perceived beneficial effects, relatives feeling in control-ICU healthcare providers' concerns about loss of control. Preferences for potential essential care activities vary. Relatives want an invitation and support from ICU healthcare providers. Themes regarding capacities were knowledge, skills, education and training, and organisational conditions.

CONCLUSIONS

Implementation of family participation in essential care requires education and training of relatives and ICU healthcare providers to address safety and quality of care concerns, though most studies lack further specification.

The family in preventing delirium in the intensive care unit: Scoping review

INTRODUCTION

Delirium is cognitive impairment related to negative inpatient outcomes in the Intensive Care Unit (ICU), family interventions have been shown to be effective in reducing the incidence of this condition.

OBJECTIVE

To identify strategies that include the family in the prevention of delirium in the adult intensive care unit that can be integrated into ABCDEF.

INCLUSION CRITERIA

Studies describing actions and interventions involving caregivers and family members in the ICU for the prevention of delirium, conducted in the last five years, available in full text, in English and Spanish, Portuguese and in adults.

METHODS

A scope review was conducted using the keywords "Critical Care, Delirium, Family, Primary Prevention" in 11 databases (PubMed, Virtual Health Library, Cochrane Library, TRIP Data base, EBSCO, Ovid Nursing, Springer, Scopus, Dialnet, Scielo, Lilacs) and other sources (Open Gray, Google Scholar), between August - October 2019; 8 studies were considered relevant and were analysed.

RESULTS

The results were described in 3 categories: flexibility vs. restriction of visits in the ICU, Reorientation as a prevention strategy and post-ICU syndrome in the family.

CONCLUSION

Extended visits, development of family-mediated activities, and redirection are non-pharmacological strategies that reduce the incidence of delirium in the ICU and offer multiple benefits to the patient and family/caregiver.

Perceptions and ideas of critically ill patients, their family and staff members regarding family participation in the physiotherapy-related care of critically ill patients: a qualitative study

BACKGROUND

Involvement of families in physiotherapy-related tasks of critically ill patients could be beneficial for both patients and their family. Before designing an intervention regarding family participation in the physiotherapy-related care of critically ill patients, there is a need to investigate the opinions of critically ill patients, their family and staff members in detail.

OBJECTIVE

Exploring the perceptions of critically ill patients, their family and staff members regarding family participation in physiotherapy-related tasks of critically ill patients and the future intervention.

METHODS

A multicenter study with a qualitative design is presented. Semistructured interviews were conducted with critically ill patients, family and intensive care staff members, until theoretical saturation was reached. The conventional content method was used for data analyses.

RESULTS

Altogether 18 interviews were conducted between May 2019 and February 2020. In total, 22 participants were interviewed: four patients, five family members, and 13 ICU staff members. Six themes emerged: 1) prerequisites for family participation (e.g., permission and capability); 2) timing and interactive aspects of engaging family (e.g., communication); 3) eligibility of patients and family (e.g., first-degree relatives and spouses, and long stay patients); 4) suitability of physiotherapy-related tasks for family (e.g., passive, active and breathing exercises); 5) expected effects (e.g., physical recovery and psychological wellbeing); and 6) barriers and facilitators, which may affect the feasibility (e.g., safety, privacy, and responsibility).

CONCLUSION

Patients, family members and staff members supported the idea of increased family participation in physiotherapy-related tasks and suggested components of an intervention. These findings are necessary to further design and investigate family participation in physiotherapy-related tasks.

Delirium-related distress in the ICU: A qualitative meta-synthesis of patient and family perspectives and experiences

BACKGROUND

Better understanding of patient and family member experiences of delirium and related distress during critical care is required to inform the development of targeted nonpharmacologic interventions.

OBJECTIVE

To examine and synthesize qualitative data on patient and family member delirium experiences and relieving factors in the Intensive Care Unit (ICU).

DESIGN

We conducted a systematic review and qualitative meta-synthesis. Eligible studies contained adult patient or family quotes about delirium during critical care, published in English in a peer-reviewed journal since 1980. Data sources included PubMed, Embase, CINAHL, PsycINFO, Web of Science, Cochrane and Clinicaltrials.gov.

METHODS

Systematic searches yielded 3238 identified articles, of which 14 reporting 13 studies were included. Two reviewers independently extracted data into a Microsoft Excel spreadsheet. Qualitative meta-synthesis was performed through line-by-line coding of relevant quotes, organization of codes into descriptive themes, and development of analytical themes. Five patients/family members with experience of ICU delirium contributed to the thematic analysis.

RESULTS

Qualitative meta-synthesis resulted in four major themes and two sub-themes. Key new patient and family-centric insights regarding delirium-related distress in the ICU included articulation of the distinct emotions experienced during and after delirium (for patients, predominantly fear, anger and shame); its 'whole-person' nature; and the value that patients and family members placed on clinicians' compassion, communication, and connectedness.

CONCLUSIONS

Distinct difficult emotions and other forms of distress are experienced by patients and families during ICU delirium, during which patients and families highly value human kindness and empathy. Future studies should further explore and address the many facets of delirium-related distress during critical care using these insights and include patient-reported measures of the predominant difficult emotions.

The family in preventing delirium in the intensive care unit: Scoping review

INTRODUCTION

Delirium is cognitive impairment related to negative inpatient outcomes in the Intensive Care Unit (ICU), family interventions have been shown to be effective in reducing the incidence of this condition.

OBJECTIVE

To identify strategies that include the family in the prevention of delirium in the adult intensive care unit that can be integrated into ABCDEF.

INCLUSION CRITERIA

Studies describing actions and interventions involving caregivers and family members in the ICU for the prevention of delirium, conducted in the last five years, available in full text, in English and Spanish, Portuguese and in adults.

METHODS

A scope review was conducted using the keywords "Critical Care, Delirium, Family, Primary Prevention" in 11 databases (PubMed, Virtual Health Library, Cochrane Library, TRIP Data base, EBSCO, Ovid Nursing, Springer, Scopus, Dialnet, Scielo, Lilacs) and other sources (Open Gray, Google Scholar), between August - October 2019; 8 studies were considered relevant and were analysed.

RESULTS

The results were described in 3 categories: flexibility vs. restriction of visits in the ICU, Reorientation as a prevention strategy and post-ICU syndrome in the family.

CONCLUSION

Extended visits, development of family-mediated activities, and redirection are non-pharmacological strategies that reduce the incidence of delirium in the ICU and offer multiple benefits to the patient and family/caregiver.

Caregiver willingness to provide care in the ICU: A concept analysis

AIM

The purpose of this paper is to conceptually define "caregiver willingness" for application to a family member providing care to a critically ill loved one during an intensive care unit (ICU) hospitalization.

BACKGROUND

Delivering care to a family member may have psychological benefits for both the caregiver and the critically ill loved one; however, the willingness of family members to provide care is an elusive concept. Examination of the "caregiver willingness" concept will help to advance nursing science.

DESIGN

Walker and Avant's eight step strategy guided identification of the defining attributes, empirical referents, antecedents, and consequences of "caregiver willingness."

DATA SOURCE

Academic Search Complete, CINAHL, MEDLINE, APA PsycInfo, and Psychology and Behavioral Health Collections were used to search for literature published between 2000 and 2020.

REVIEW METHODS

A literature search was conducted using keywords, such as "caregiver," "willingness," "willing to care," "family or families or relatives or siblings or caregiver," and "critically ill or intensive care or ICU or critical care."

RESULTS

A definition of caregiver willingness was constructed and defined as "a family member or significant other's affirmation or acknowledgment of openness to engage in the physical and/or emotional supportive care of a loved one who is critically ill and cannot perform self-care."

CONCLUSION

The definition provides a foundation for instrument development to measure caregiver willingness and possible theory expansion for family engagement and caregiving in the ICU.

Patients, family members and providers perceive family-administered delirium detection tools in the adult ICU as feasible and of value to patient care and family member coping: a qualitative focus group study

PURPOSE

While studies report on perceptions of family participation in delirium prevention, little is known about the use of family-administered delirium detection tools in the care of critically ill patients. This study sought the perspectives of patients, their family members, and healthcare providers on the use of family-administered delirium detection tools to detect delirium in critically ill patients and barriers and facilitators to using family-administered delirium detection tools in patient care.

METHODS

In this qualitative study, critical care providers (five physicians, six registered nurses) and participants from the Family ICU Delirium Detection Study (seven past patients and family members) took part in four focus groups at one hospital in Calgary, Alberta.

RESULTS

Key themes identified following thematic analysis from 18 participants included: 1) perceptions of acceptability of family-administered delirium detection (e.g., family feels valued, intensive care unit (ICU) care team may not use a family member's results, intensification of work load), 2) considerations regarding feasibility (e.g., insufficient knowledge, healthcare team buy-in), and 3) overarching strategies to support implementation into routine patient care (e.g., value of family-administered delirium detection for patients and families is well understood in the clinical context, regular communication between the family and ICU providers, an electronic version of the tool).

CONCLUSIONS

Patients, family members and healthcare providers who participated in the focus groups perceived family participation in delirium detection and the use of family-administered delirium detection tools at the bedside as feasible and of value to patient care and family member coping.

TRIAL REGISTRATION

www.ClinicalTrials.gov (NCT03379129); registered 15 December 2017.

Effectiveness of an intensive care unit family education intervention on delirium knowledge: a pre-test post-test quasi-experimental study

PURPOSE

To create, validate, and refine an intensive care unit (ICU) delirium education intervention to prepare family members to partner with the ICU care team to detect delirium symptoms and prevent and manage delirium using nonpharmacological strategies.

METHODS

In this pre-test post-test quasi-experimental study, consecutive eligible family members of critically ill patients admitted to an ICU completed an ICU Family Education Delirium intervention in two parts: 1) six-minute video on ICU delirium (risk factors, prevention/management, symptoms, communication with the ICU care team), and 2) two case vignettes to practice detecting delirium using family-administered delirium detection questionnaires (Family Confusion Assessment Method [FAM-CAM] and Sour Seven). Family members' delirium knowledge was measured before, immediately after, and two weeks following the intervention using the Caregiver ICU Delirium Knowledge Questionnaire (CIDKQ).

RESULTS

Of 99 family members recruited over eight months, 81 (82%) completed the intervention and 63 (63/81, 78%) completed all follow-up questionnaires. Family members' delirium knowledge improved significantly following the intervention (pre-CIDKQ, 14; 95% confidence interval [CI], 13 to 15; post-CIDKQ, 17; 95% CI, 16 to 17; P < 0.001) and was retained two weeks after the intervention (CIDKQ 16; 95% CI, 16 to 17; P < 0.001). This included increased knowledge regarding delirium risk factors (e.g., medication, mechanical ventilation), prevention/management (e.g., orientation, day/night routine), and symptoms of delirium. More family members correctly detected delirium symptoms in case vignettes using the Sour Seven (92%) compared with the FAM-CAM (78%).

CONCLUSIONS

A video-based ICU delirium education intervention is effective in educating family members about prevention, detection, and management of delirium.

How is family involved in clinical care and decision-making in intensive care units? A qualitative study

Background: Involving family members in patient care is considered as a significant dimension of family-centered care in intensive care units (ICUs). Aims: To describe family members' perceptions and experiences regarding involvement in clinical care delivery and decision-making in ICUs in Iran. Design: A qualitative research method using conventional content analysis. Methods: A total number of 24 participants were selected through purposive sampling method between 2018 and 2019. Each interview also lasted between 30 and 60 min and the inductive data analysis was used. Results: The findings revealed that non-agreed involvement in clinical care delivery and family involvement in decision-making is being implemented on a continuum of paternalistic views. Conclusion: Healthcare providers, particularly nurses, and policy makers can thus exploit these findings to strengthen family involvement in this regard and consequently improve quality of care. Impact statement: A non-agreed approach and paternalistic views along with some barriers can affect family members' involvement in providing clinical care and making decisions in ICUs in Iran.

Family participation in the care of older adult patients admitted to the intensive care unit: A scoping review

BACKGROUND

Family members' participation in care is internationally advocated as a way to improve patient outcomes admitted to the intensive care unit (ICU).

OBJECTIVE

to provide an overview of current understandings about family participation in the care of older adult patients admitted to ICU.

DESIGN, DATA SOURCES, AND METHODS

The Arksey and O'Malley's framework for scoping review was used. We searched PubMed, CINAHL, EmBase, Scopus, and Cochrane from their inception until 10 October 2019 to answer this question: What are the dimensions, prerequisites, facilitators, barriers, and consequences of family member's participation in the care of older adult patient admitted to ICU?

RESULTS

Of 3410 search results, 33 articles were included (10 descriptive; 3 interventional or quality improvement project; 12 qualitative; 5 reviews; 1 expert opinion; 1 evidence-practice recommendation and 1 clinical guideline). The included studies were conducted internationally (n = 7), USA (n = 8), Canada (n = 3), France (n = 2), Britannia, Australia (n = 6), (n = 2), and Sweden (n = 5). No article from Asian and African countries was retrieved. The supporting level of evidence for most studies (28 out of 33) was low.

CONCLUSIONS

This review showed that family members could participate in the provision of physical and non-physical care (emotional, mental, cognitive, and psychosocial) to older adult patients admitted to ICU. Their participation in ICU care has the potential to improve the physical, emotional, psychological and psychological outcomes of older adult patients and their family members as well as reduce the burden of the healthcare system. The barriers were grouped into patient-related factors, ICU staff-related factors, family-related factors, and ICU setting-related factors. In addition, several facilitators of participation in ICU care were discussed.

THE IMPLICATION FOR FUTURE RESEARCH

This review showed a lack of experimental studies on the effectiveness of family members' participation in ICU care for the patient, family, and care system. This provides an opportunity for future research to develop and test interventions based on the multiple dimensions described in this paper.

A study protocol for a randomized controlled trial of family-partnered delirium prevention, detection, and management in critically ill adults: the ACTIVATE study

Background

Delirium is very common in critically ill patients admitted to the intensive care unit (ICU) and results in negative long-term outcomes. Family members are also at risk of long-term complications, including depression and anxiety. Family members are frequently at the bedside and want to be engaged; they know the patient best and may notice subtle changes prior to the care team. By engaging family members in delirium care, we may be able to improve both patient and family outcomes by identifying delirium sooner and capacitating family members in care.

Methods

The primary aim of this study is to determine the effect of family-administered delirium prevention, detection, and management in critically ill patients on family member symptoms of depression and anxiety, compared to usual care. One-hundred and ninety-eight patient-family dyads will be recruited from four medical-surgical ICUs in Calgary, Canada. Dyads will be randomized 1:1 to the intervention or control group. The intervention consists of family-partnered delirium prevention, detection, and management, while the control group will receive usual care. Delirium, depression, and anxiety will be measured using validated tools, and participants will be followed for 1- and 3-months post-ICU discharge. All analyses will be intention-to-treat and adjusted for pre-identified covariates. Ethical approval has been granted by the University of Calgary Conjoint Health Research Ethics Board (REB19–1000) and the trial registered. The protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist.

Discussion

Critically ill patients are frequently unable to participate in their own care, and partnering with their family members is particularly important for improving experiences and outcomes of care for both patients and families.

Trial registration

Registered September 23, 2019 on Clinicaltrials.gov NCT04099472.

Meaning and comfort factors in the paediatric intensive care unit from an adult perspective: a descriptive phenomenological study

AIMS

To explore the meaning of comfort and know the factors that contribute to it from the point of view of the young adults who received care in a paediatric intensive care unit, the family of the patient and the interdisciplinary team attending the patient.

FINDINGS

A total of 30 people were invited to participate in the focus groups; 24 did so. Thematic analysis yielded the following common categories: meaning of comfort, environmental factors in paediatric intensive care unit, family accompaniment during paediatric intensive care unit stay, management of information in the paediatric intensive care unit and, finally, the intimacy and privacy of the critically ill paediatric patient and their family.

CONCLUSIONS

Paediatric intensive care unit professionals need to consider not only the environmental input that may lead to discomfort but also aspects such as continuous family accompaniment, the sharing of complete information with the family and the promoting of privacy.

Do health care professionals worry about delirium? Relatives' experience of delirium in the intensive care unit: A qualitative interview study

OBJECTIVES

In intensive care units, there is a high incidence of delirium, which relates to the risk of complications. Engagement of relatives is an acknowledged part of handling delirium, but knowledge of relatives' perspectives is lacking.

AIM

To explore relatives' experiences of delirium in the critically ill patient admitted to an intensive care unit.

RESEARCH DESIGN

A qualitative design with a phenomenological approach. Semi-structured interviews with eleven relatives of critically ill patients who had delirium during admission to the intensive care unit.

SETTING

An intensive care unit in Denmark.

FINDINGS

Three categories emerged: 'Delirium is not the main concern', 'Communication with health-care professionals is crucial', and 'Delirium impacts on relatives'. Relatives had a lack of knowledge of delirium. Symptoms of delirium were thought of as a natural consequence of critical illness and seemed to be a secondary problem. Health-care professionals did not talk about delirium and information was requested. Delirium and the manifestation of it was experienced in different ways and brought different ways of coping.

CONCLUSION

Findings give a new insight into relatives' experience of delirium in the intensive care unit. Relatives need more information to better understand delirium. Future research must investigate the potential in helping relatives to cope with delirium, to the benefit of both patient and relatives.