Perceptions of Family Members, Nurses, and Physicians on Involving Patients' Families in Delirium Prevention

Health care providers' perceptions of family participation in essential care in the intensive care unit: A qualitative study

BACKGROUND

Family participation in essential care may benefit patients and relatives.

AIM

To examine the needs, perceptions and preferences of health care providers about family participation in essential care in the adult intensive care unit.

STUDY DESIGN

A qualitative descriptive study using inductive thematic analysis. Three focus group interviews with a total of 30 intensive care unit health care providers, consisting of 20 critical care nurses, one nursing assistant, five physicians, three physical therapists and one speech therapist working in three Dutch intensive care units.

RESULTS

One overarching theme, balancing interests, and four main themes emerged: looking after the patient's interests, taking the relatives' perspective into account, looking after interests of intensive care unit health care providers and conditions for family participation. The first theme, looking after the patient's interests, included three sub-themes: insecurity about patient's wishes and needs, patient safety concerns and potential benefits for the patient. The second theme, taking the relatives' perspective into account, was also characterized by three sub-themes: concerns about the relatives' possible burden, potential benefits for the relative and the relationship between patient and relative. The third theme, looking after interests of intensive care unit health care providers, included three sub-themes: attitude towards family participation in essential care, differing perceptions of essential care and concerns about intensive care unit health care provider's burden. The last theme, conditions for family participation, included two sub-themes: establishing a relationship and considering family participation in essential care as a process.

CONCLUSIONS

Health care providers' perceptions and preferences regarding family participation in essential care in the intensive care unit are summarized in the overarching theme balancing interests. This overarching theme also reflects the needs and perceptions of patients and relatives.

RELEVANCE TO CLINICAL PRACTICE

These findings may support critical care nurses and other health care providers when encouraging family participation in essential care.

Evaluation of the Quality of Delirium Website Content for Patient and Family Education: Cross-Sectional Study

BACKGROUND

Patients and families who have experienced delirium may seek information about delirium online, but the quality and reliability of online delirium-related websites are unknown.

OBJECTIVE

This study aimed to identify and evaluate online delirium-related websites that could be used for patient and family education.

METHODS

We searched Microsoft Bing, Google, and Yahoo using the keywords "delirium" and the misspelled "delerium" to identify delirium-related websites created to inform patients, families, and members of the public about delirium. The quality of identified delirium-related website content was evaluated by 2 authors using the validated DISCERN tool and the JAMA (Journal of the American Medical Association) benchmark criteria. Readability was assessed with the Simple Measure of Gobbledygook, the Flesch Reading Ease score, and the Flesch Kincaid grade level. Each piece of website content was assessed for its delirium-related information using a checklist of items co-designed by a working group, which included patients, families, researchers, and clinicians.

RESULTS

We identified 106 websites targeted toward patients and families, with most hospital-affiliated (21/106, 20%) from commercial websites (20/106, 19%), government-affiliated organizations (19/106, 18%), or from a foundation or advocacy group (16/106, 15%). The median time since the last content update was 3 (IQR 2-5) years. Most websites' content (101/106, 95%) was written at a reading level higher than the recommended grade 6 level. The median DISCERN total score was 42 (IQR 33-50), with scores ranging from 20 (very poor quality) to 78 (excellent quality). The median delirium-related content score was 8 (IQR 6-9), with scores ranging from 1 to 12. Many websites lacked information on the short- and long-term outcomes of delirium as well as how common it is. The median JAMA benchmark score was 1 (IQR 1-3), indicating the quality of the websites' content had poor transparency.

CONCLUSIONS

We identified high-quality websites that could be used to educate patients, families, or the public about delirium. While most delirium-related website content generally meets quality standards based on DISCERN and JAMA benchmark criteria, high scores do not always ensure patient and family-friendliness. Many of the top-rated delirium content were text-heavy and complex in layout, which could be overwhelming for users seeking clear, concise information. Future efforts should prioritize the development of websites with patients and families, considering usability, accessibility, and cultural relevance to ensure they are truly effective for delirium education.

Family involvement in preventing delirium in critically ill patients: A systematic review and meta-analysis

BACKGROUND

Humanized care is a novel concept in the prevention of delirium, with family involvement being a crucial component. Currently, there is controversy regarding the effectiveness of family involvement in preventing delirium among critically ill patients, and the impact of varying levels of family involvement on delirium prevention remains unclear.

OBJECTIVE

The purpose of this study is twofold: (a) to investigate the influence of family involvement on delirium among critically ill patients, and (b) to explore the effectiveness of different levels of family involvement in preventing delirium in these patients.

DESIGN

A systematic review and meta-analysis.

METHODS

From database inception to July 2024, a comprehensive search was conducted across PubMed, EMBASE, CINAHL, Web of Science, and the Cochrane CENTRAL database. Randomized controlled trials that examined family involvement were included in the review.

RESULTS

This review included a total of 11 randomized controlled trials, encompassing 3113 critically ill patients. Family involvement was found to significantly reduce the incidence of delirium among critically ill patients (RR = 0.46, 95%CI = 0.31 to 0.69), decrease the duration of delirium (WMD = -2.18, 95 % CI = -4.14 to -0.22), and shorten the length of Intensive Care Unit (ICU) stay (WMD = -1.46, 95%CI = -2.43 to -0.50). Three different levels of family involvement-direct participation in care (RR = 0.37, 95%CI = 0.26 to 0.51), family visits and companionship (RR = 0.56, 95 % CI = 0.25 to 1.25), and indirect participation (RR = 0.77, 95 % CI = 0.29 to 2.07)-varies in their effectiveness for delirium prevention.

CONCLUSIONS

Family involvement significantly impacts delirium prevention in critically ill patients. The effectiveness of delirium prevention varies depending on the level of family involvement, with direct participation of family members in caregiving demonstrating a more pronounced effect in reducing delirium incidence among critically ill patients.

REGISTRATION

The review protocol has been registered in the PROSPERO International prospective register of systematic reviews (CRD42024563095).

Promoting Family Involvement in the Management of Delirium in Intensive Care: Scoping Review

Background: In recent years, family involvement in ICU patient care has become increasingly significant. Family involvement in delirium management, while desirable, can be difficult for loved ones. Therefore, every attempt should be made and interventions developed to promote and support the family in this process. The aim of this review was to analyze the available literature on interventions and strategies used by ICU staff to support and promote family involvement in the management of delirium in critically ill patients. Methods: The databases searched included the following: MEDLINE, CINAHL, and the Cochrane Library. Studies were included in the review if they were conducted in adult intensive care units and/or addressed interventions to support and promote family/relatives' involvement in delirium management. Findings: A total of 368 database articles were reviewed. After removing duplicates and checking for inclusion and exclusion criteria, four articles were finally included in the analysis. Research gaps and content analysis identified promotional and supportive interventions for family involvement in delirium management: (I) Education; (II) Mentoring; (III) Partnership. Conclusions: Research gaps to be filled are as follows: (I) the scope of interventions that support and promote family involvement in delirium management; (II) interventions that enhance feelings of efficacy among family members and reduce symptoms of anxiety and depression; and (iii) the impact of specific interventions on patients' delirium outcomes.

Opinions of Patients, Families and Healthcare Professionals on Family Involvement in the Care of Patients Hospitalized in a Moroccan University Hospital: A Cross-Sectional Observational Survey

Opinion surveys on family participation in care in non-Western countries are rare. This study aims to assess the opinions of patients, families, and healthcare professionals regarding family involvement in care to identify their preferences and the associated factors. A cross-sectional survey was conducted over eight months involving 717 participants, using structured questionnaires at the Acute Assessment Unit of a university hospital in Morocco. Comparative analyses examined the association between participant characteristics and the preferences of care categories. Poisson regression was applied to determine factors associated with participant preferences. Attitudes toward family participation in care were positive, with an average score of 3.62 ± 0.43 on a 4-point Likert scale. Healthcare professionals were more favorable towards family participation, with an average of 10.6 ± 2.44 types of care, compared to 7.17 ± 1.96 for families and 5.71 ± 2.16 for patients. Participants' opinions converged on a set of simple and less technical care tasks. Factors significantly associated with patient preferences in the final adjustment model (p < 0.05) included frailty, loss of autonomy, length of stay, and regular and continuous (day and night) family presence. This study highlights the strong support of health professionals, patients, and families for family participation in care. Understanding these preferences and related factors is essential to maximize family participation and develop a model of Patient And Family Centered Care adapted to the Moroccan context.

Exploring patients' and families' preferences for auditory stimulation in ICU delirium prevention: A qualitative study

OBJECTIVES

To explore the preferences of patients and families for delirium prevention by auditory stimulation in intensive care units.

RESEARCH METHODOLOGY

One-on-one, face-to-face, semistructured interviews with 17 participants (6 patients and 11 family members) were conducted at a step-down unit in a tertiary general hospital using a descriptive qualitative design. The data were analyzed via inductive thematic analysis.

RESULTS

Four major themes and ten subthemes emerged from the interviews: (1) reality orientation; (2) emotional support; (3) links to the outside; and (4) promising future.

CONCLUSIONS

The results in this qualitative study shed light on patients' and families' preferences for auditory stimulation in preventing ICU delirium. The participation of family members plays a crucial role in preventing ICU delirium. Family members can assist patients in reducing confusion about the situation by providing accurate and clear reality orientation. The emotional support and promising future provided by family members can help patients regain confidence and courage, which are often lacking in ICU patients. Linking patients to the outside world helps them stay connected, understand what is happening outside and reduce feelings of isolation.

IMPLICATIONS FOR CLINICAL PRACTICE

These findings can help health care staff gain insight into patients' and families' preferences and needs for auditory stimulation. Furthermore, these findings pave the way for crafting effective auditory interventions.

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.

Nurses' experiences of provision family-centred care in the postresuscitation period: A qualitative study

AIM

This study aimed to explore nurses' experiences of providing family-centred care in the postresuscitation period.

DESIGN

An exploratory-descriptive qualitative design was used.

METHODS

In this qualitative study, in-depth, semi-structured interviews were conducted with 22 nurses in three educational hospitals. There were six participants who completed follow-up interviews to resolve questions generated during initial interviews. Data were analysed using conventional content analysis.

RESULTS

Five main categories were extracted: continuous monitoring, facilitation of attendance, involvement in care, informing and emotional support. Despite the lack of organizational policies and guidelines, nurses explained how they work to provide family-centred care for families, especially those they assessed as having less possibility of aggressive behaviour and those with a better understanding of their loved one's condition. To provide postresuscitation family-centred care, nurses facilitated family attendance, involved them in some basic nursing care, and provided information and emotional support to the family members.

CONCLUSION

Nurses attempted to follow the basic principles of family-centred care in the postresuscitation period. However, to improve the provision of care by nurses, it is necessary to embed family-centred care principles in institutional policies and guidelines and to conduct training for nurses.

IMPLICATIONS FOR THE PROFESSION

Iranian nurses are interested in engaged families in the postresuscitation period. Correct implementations of such care that include all families need institutional policies and guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Intensive care professionals' perceptions of the quality of counselling provided in the ICU: A cross-sectional study

BACKGROUND

Intensive care professionals (ICPs) have a key role in counselling adult intensive care unit (ICU) patients and their family members. The counselling provided to ICU patients and their family members can be described based on the content, implementation, benefits, and resources.

AIMS

The study had two specific aims: first, to assess ICPs' perceptions of the quality of counselling provided to ICU patients and their family members; and second, to explore which factors ICPs feel is associated with the quality of counselling.

STUDY DESIGN

A cross-sectional survey of ICPs working in adult ICUs in Finnish university hospitals. Data were collected using the Counselling Quality Instrument. The data were analysed by descriptive statistics and chi-square and t-test statistical methods.

RESULTS

A total of 182 ICPs returned the questionnaire, reflecting a response rate of 18.6%. Most of the respondents were nurses (97%) and the mean age was 42 years. The ICPs reported having adequate time for patient- (77%) and family-centered (73%) counselling, but only 47% felt that their units had the appropriate facilities. There were statistically significant differences between patient- and family-centered counselling and the ICP's self-assessed competence (p < .001), goal-oriented counselling (p < .001), and atmosphere during counselling (p < .001). ICPs' attitudes towards counselling impacted how these professionals assessed patients' and family members' confidence, along with patient recovery (p < .001).

CONCLUSIONS

This study confirms that the provision of high-quality counselling has beneficial effects; however, it also indicates that there is a need for training that considers each ICP's professional experience and patient- and family-centered factors, which may differ from one another.

RELEVANCE TO CLINICAL PRACTICE

According to ICPs, the quality of counselling can be enhanced by empowering ICPs to improve counselling and providing appropriate ICU facilities for counselling, such as a private room for family members.

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.

Educational intervention for family caregivers of older adults with delirium: An integrative review

AIM

To propose educational strategies to prevent delirium in older adults.

DESIGN

Integrative review.

METHODS

This review followed the methodology of Whittemore and Knafl (J Adv Nurs 52(5):546-553, 2005. 10.1111/j.1365-2648.2005.03621.x).

DATA SOURCES

A literature search was performed of the PubMed, CINAHL, Embase, Cochrane Library CENTRAL, and Scopus databases on 8 July 2022.

RESULTS

Three themes of educational interventions were identified: capacity building, resource provision and enhancement of relationships, collectively termed Fa-CARE. Educational interventions improved family caregivers' knowledge about delirium, their anxiety; depression; self-efficacy; and attitudes. Among older adults, these interventions improved the duration, severity and incidence of delirium; functional abilities; and length of hospital stay.

CONCLUSION

Providing education to family caregivers benefits both those caregivers and the older adults. When planning educational intervention, diverse and innovative approaches need to be considered.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

This study can guide family education regarding the care of older adults with delirium.

IMPACT

Educational interventions positively impacted both family caregivers and older adults with delirium. Educational interventions provide family caregivers with resources, improve their capacity for delirium management, and enhance their relationships with older adults. This study suggests future directions in education for family caregivers of older adults with delirium.

REPORTING METHOD

This review adhered to the EQUATOR guidelines by using the PRISMA 2020 checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Delirium Care by Intensive Care Unit Nurses: Focus Group Studies in a Medical Center of Southern Taiwan

OBJECTIVES

Studies have identified many nursing interventions that can prevent delirium and fall accidents in clinical patients, detect and treat delirium early to prevent functional decline in the patient, shorten hospitalization duration, and lower the death rate. This study aimed to explore delirium care by intensive care unit (ICU) nurses in a medical center of southern Taiwan.

METHODS

This study conducted 3 semistructured focus group interviews, each for a single medical ICU, involving groups of 6 to 8 nurses each. The nurses were recruited through purposive sampling. This research was approved by an institutional review board in the medical center of southern Taiwan from March 31, 2020, to January 30, 2021. The co-principal investigator described the purpose and process of this study to the participants before they provided their written informed consents. The interviews were conducted in the meeting room and were audiotape recorded. The recordings were transcribed and subject to content analysis to identify the themes of delirium care.

RESULTS

For nursing interventions of delirium, satisfying the patient's physical needs: comfort care, massages, and early rehabilitation; and psychological care: being presence, communication, and ensuring familial support were included. In terms of environmental interventions for delirium, providing reorientation, music, light, belongings with sentimental value, and audiovisual equipment were included. However, according to the recruited medical ICU nurses, these nonpharmacological interventions, although effective, do not have long-lasting effects. Finally, nurses reported themselves as having been attacked by patients with delirium. Thus, they all agreed that restraining patients with delirium may be necessary, but restraining is a double-edged sword for ICU delirium patients.

CONCLUSIONS

Research team suggests for future studies to extend their evidence-based findings of physical, psychological, and environmental care for ICU delirium patients toward integrating the efforts of various health care professionals.

Family members' perceptions of counselling during visits to loved ones in an adult ICU

AIMS

The study's aims were to (1) assess family members' perceptions of the quality of the counselling they received while visiting a loved one in an adult ICU and (2) identify factors that influence family members' perceptions of counselling quality.

DESIGN

A cross-sectional survey of visiting family members of adult ICU patients.

METHODS

Family members (n = 55) at eight ICUs across five Finnish university hospitals completed a cross-sectional survey.

RESULTS

Family members assessed the quality of counselling in adult ICUs to be good. Factors associated with the quality of counselling were knowledge, family-centred counselling, and interaction. Family members' ability to live normally was associated with understanding of the loved one's situation (ρ = 0.715, p < 0.001). Interaction was associated with understanding (ρ = 0.715, p < 0.001). Family members felt that intensive care professionals did not adequately ensure that they understood counselling-related issues and that they lacked opportunities to give feedback, in 29% of cases, staff asked the family members whether they understood the counselling and 43% of family members had opportunities to offer feedback. However, the family members felt that the counselling they received during ICU visits was beneficial.

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.

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.

Prevention and treatment of delirium in intensive care: Hermeneutics of experiences of the nursing team

OBJECTIVE

To understand the experiences in nursing care in the prevention and treatment of delirium in people hospitalized in intensive care units.

METHODOLOGY

Hermeneutic phenomenological qualitative study. The selection of participants was by intentional sampling: seven nursing assistants and eight nurses. Theoretical saturation was achieved. The phenomenological interview was applied to collect data from a central question and the analysis was carried out following the approaches of Heidegger's hermeneutical circle.

RESULTS

Four significant themes emerged from the analysis: (1) delirium prevention, (2) pharmacological treatment, (3) non-pharmacological treatment, and (4) barriers to non-pharmacological treatment. These themes were accompanied by 35 interrelated units of meaning: in the first theme, the most repetitive units were communication, orientation, and family bonding; in the second was the use of pharmacological treatment only in the acute phase; in the third was the modification of the environment according to the patient's preference (where the family is a priority and strategies that provide cognitive and social stimulation can be reinforced), and in the fourth was the work overload for the nursing team.

CONCLUSIONS

The experiences of the nursing team in the prevention and treatment of delirium in critically ill patients highlight that communication allows an approach to the patient as a human being immersed in a reality, with a personal history, needs and preferences. Therefore, family members must be involved in these scenarios, as they can complement and support nursing care.

[The nurse's role in preventing delirium in critically ill adult/elderly patientsEl papel de la enfermera en la prevención del delirio en el paciente adulto/anciano críticamente enfermo]

Introduction

Delirium is an acute brain dysfunction, associated with increased mortality and morbidity, which often affects critically ill adult/elderly patients. Nurses have a crucial role in the prevention/control of delirium, through the implementation of non-pharmacological interventions.

Objective

To know the nursing interventions in the identification, prevention and control of delirium in adult/critical elderly patients.

Materials and Methods

An Integrative Literature Review of articles published between 2014 and 2018 was carried out, which identified nursing interventions aimed at the prevention and control of delirium in adult/ critical elderly patients. Four searches were carried out, in the electronic databases of EBSCOhost and B-on.

Results

13 studies were identified, which present nursing interventions, mostly non-pharmacological, for the prevention and control of delirium in adult/critical elderly patients. Of these, interventions related to the environment, sleep promotion, early therapeutic intervention, cognitive assessment and patient orientation, interventions systematized in protocols, as well as interventions aimed at the participation of family members, the training of nurses and the teaching of patients are evident. Risk factors for the development of delirium and assessment tools were also identified.

Discussion

The prevention of delirium is important and imperative, since its occurrence in critically ill patients is associated with increased mortality, morbidity, length of stay and a high hospital cost. The identification of risk factors for the occurrence of delirium should be included in delirium management protocols.

Conclusions

Evidence has shown that nurses are essential in the early identification, prevention and control of delirium, preventing the progression of the disease, contributing to the reduction of morbidity and mortality. The nursing intervention must include the identification of predisposing and/or precipitating factors to contribute to the reduction of the occurrence and/or resolution of delirium.

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.

Benefits of Patient/Caregiver Engagement in Adverse Drug Reaction Reporting Compared With Other Sources of Reporting in the Inpatient Setting: A Systematic Review

OBJECTIVES

Clinicians learn from prior adverse events through pharmacovigilance allowing for improved medication safety in the medication use process; therefore, adverse drug reaction (ADR) reporting needs to be maximized. This systematic review was conducted to determine whether engaging patients/caregivers in ADR reporting during a patient's hospitalization provides further information about ADRs not obtained from traditional sources of reporting (i.e., voluntary reporting, medical record review).

METHODS

This review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A literature search was conducted from January 2018 to June 2019 in PubMed, CINAHL, and Embase. Studies were included if they were (i) conducted in the inpatient setting, (ii) surveyed patients/caregivers, (iii) compared patient/caregiver reporting with another source of reporting, and (iv) evaluated ADRs. Studies completed in an outpatient setting or nursing home were excluded.

RESULTS

A total of 11 studies were included. Sources of ADR information from patient/caregiver were obtained through interviews, surveys, questionnaires, or open-ended responses. Patient reporting was compared with medical record reports (7 articles) and health care professional reporting (4 articles). Approximately 11% to 35% of ADRs reported from patients were not identified through voluntary reporting by health care professionals, and 5.6% to 66% of ADRs obtained from patient reporting were not provided in the medical record.

CONCLUSIONS

Patients/caregivers are important sources of safety information to improve system and practice of medication use that may not be recorded by other surveillance methods. Administrators and clinicians need to determine the best approach to integrate patients/caregivers into routine reporting for optimal engagement.

Prevention and treatment of delirium in intensive care: Hermeneutics of experiences of the nursing team

OBJECTIVE

To understand the experiences in nursing care in the prevention and treatment of delirium in people hospitalized in intensive care units.

METHODOLOGY

Hermeneutic phenomenological qualitative study. The selection of participants was by intentional sampling: seven nursing assistants and eight nurses. Theoretical saturation was achieved. The phenomenological interview was applied to collect data from a central question and the analysis was carried out following the approaches of Heidegger's hermeneutical circle.

RESULTS

Four significant themes emerged from the analysis: 1) Delirium prevention, 2) Pharmacological treatment, 3) Non-pharmacological treatment, and 4) Barriers to non-pharmacological treatment. These themes were accompanied by 35 interrelated units of meaning: in the first theme, the most repetitive units were communication, orientation, and family bonding; in the second was the use of pharmacological treatment only in the acute phase; in the third was the modification of the environment according to the patient's preference (where the family is a priority and strategies that provide cognitive and social stimulation can be reinforced), and in the fourth was the work overload for the nursing team.

CONCLUSIONS

The experiences of the nursing team in the prevention and treatment of delirium in critically ill patients highlight that communication allows an approach to the patient as a human being immersed in a reality, with a personal history, needs and preferences. Therefore, family members must be involved in these scenarios, as they can complement and support nursing care.

Implementation of the Family HELP Protocol: A Feasibility Project for a West Texas ICU

The purpose of this project was to determine if bedside intensive care unit (ICU) nurse buy-in to the Family Hospital Elder Life Program (HELP) protocol was sufficient to make implementation feasible at one county hospital in West Texas. Surveys were anonymous with ballot box collection being available to the bedside ICU nurses for one week each. Questions were based on literature findings of expected outcomes, identified barriers and facilitators, Calgary Family Intervention Method framework domains, and the Centers for Disease Control and Prevention Framework for program evaluation. Outcome measures were taken from the stated aims of the project and evaluated from paired baseline and summative survey questions. Survey participation was approximately half of nurses employed in the studied ICU. Analysis of the surveys showed a positive perception of family presence decreasing patient delirium symptoms, and a positive perception of the Family HELP protocol. The results described a high perception of family members as partners in care and high intention to implement the Family HELP protocol, indicating strong support of a full implementation of the protocol. The high level of bedside nurse buy-in present in this study has large implications for successful implementation of the Family HELP protocol in the near future, with sustainability and continued use supported by potential inclusion of the task in the electronic health record charting.

Implementation of ABCDEF care bundle in intensive care units: A cross-sectional survey

BACKGROUND

Delirium affects up to 80% of patients in intensive care units (ICUs) and is associated with higher mortality, physical dependence, and health care costs. The 2018 pain, agitation, delirium, immobility, and sleep guideline recommended ABCDEF care bundle for delirium prevention and management. However, limited information is available regarding the adoption of the care bundle in ICUs in Mainland China.

AIMS AND OBJECTIVES

To assess the current implementation of the ABCDEF care bundle for delirium prevention as reported by ICU nurses in Mainland China.

DESIGN

A cross-sectional study was conducted.

METHODS

A cross-sectional online survey using a validated questionnaire about the practices of the ABCDEF care bundle was conducted among 334 registered nurses in 167 ICUs of 65 cities in Mainland China.

RESULTS

Almost 50% of the sampled ICU nurses were unaware of the ABCDEF care bundle, though 86.83% of the surveyed ICUs implemented pain assessments and 95.51% implemented sedation assessments. Nearly half (46.41%) of the surveyed ICUs performed routine spontaneous awaking trials, with 21.26% performing them daily. Spontaneous breathing trials were performed in 38.32% of the surveyed ICUs. Only 47% of the surveyed ICUs routinely monitored patients for delirium. About one-third (38.35%) of the surveyed ICUs were supported by specialist teams that implemented the mobilization programmes. Most ICUs restricted the duration of family visits per day (<0.5 hour: 61.67%; 0.5-2 hours: 23.65%; >2 hours: 3.29%) and only 28.14% of the surveyed ICUs employed dedicated staff to support the families.

CONCLUSIONS

Although most of the surveyed ICUs implemented pain and sedation assessments, many of them did not implement structured delirium assessments. Early mobilization programmes and family participation should be encouraged.

RELEVANCE TO CLINICAL PRACTICE

Promoting the uses of a reliable delirium assessment tool such as Confusion Assessment Method for Intensive Care Unit patients, building an early mobilization team, and engaging family caregivers in the care plan may contribute to improved patients' clinical outcomes.

Non-pharmacologic interventions for the prevention of delirium in the intensive care unit: An integrative review

BACKGROUND

Delirium in the intensive care unit (ICU) is associated with increased mortality, longer hospital stays, and increased odds of institutionalization after discharge. Delirium is a significant complication that occurs frequently in ICU yet lacks a standardized treatment protocol. Because of the limited effective pharmacologic treatments available for the management of delirium, non-pharmacologic interventions such as early mobilization, earplugs and blinds at night, music and natural sunlight during the day, continuous reorientation, and increased visitation and family participation are essential to integrate into the treatment plan for the management of delirium in the ICU.

AIM

To summarize evidence on the use of non-pharmacologic interventions for the reduction in incidence and duration of delirium in ICU patients and to integrate qualitative studies that explore the perception of delirium in the ICU from staff and patients' families to support the use of non-pharmacologic interventions.

METHODS

For this integrative review, electronic databases PubMed, EMBASE, and Google Scholar were searched using the guidance of a librarian and second reviewer to find qualitative and quantitative studies that were published after 2005 and involved adult patients in the ICU.

CONCLUSION

Eight quantitative articles and four qualitative articles were chosen to be included in this review. All eight quantitative studies provide significant evidence (P < .05) for the efficacy of their interventions to provide benefit to at least one delirium-related outcome. The four qualitative research studies reviewed provide insight on delirium in the ICU from staff and patients' families who share a desire for the use of effective non-pharmacologic interventions.

RELEVANCE TO CLINICAL PRACTICE

Non-pharmacologic interventions used for patients in the ICU may be efficacious in reducing the incidence and duration of delirium in adults. Non-pharmacologic interventions are feasible and supported by ICU staff and patients' families and should be considered in the care of the critically ill patient.

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.

Effect of early cognitive interventions on delirium in critically ill patients: a systematic review

PURPOSE

A systematic review of the literature was conducted to determine the effects of early cognitive interventions on delirium outcomes in critically ill patients.

SOURCE

Search strategies were developed for MEDLINE, EMBASE, Joanna Briggs Institute, Cochrane, Scopus, and CINAHL databases. Eligible studies described the application of early cognitive interventions for delirium prevention or treatment within any intensive care setting. Study designs included randomized-controlled trials, quasi-experimental trials, and pre/post interventional trials. Two reviewers independently extracted data and assessed risk of bias using Cochrane methodology.

PRINCIPAL FINDINGS

Four hundred and four citations were found. Seven full-text articles were included in the final review. Six of the included studies had an overall serious, high, or critical risk of bias. After application of cognitive intervention protocols, a significant reduction in delirium incidence, duration, occurrence, and development was found in four studies. Feasibility of cognitive interventions was measured in three studies. Cognitive stimulation techniques were described in the majority of studies.

CONCLUSION

The study of early cognitive interventions in critically ill patients was identified in a small number of studies with limited sample sizes. An overall high risk of bias and variability within protocols limit the utility of the findings for widespread practice implications. This review may help to promote future large, multi-centre trials studying the addition of cognitive interventions to current delirium prevention practices. The need for robust data is essential to support the implementation of early cognitive interventions protocols.

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.

Psychometric evaluation of the family caregiver ICU delirium knowledge questionnaire

Background

Delirium is a common condition in critically ill patients, affecting nearly half of all patients admitted to an intensive care unit (ICU). Family caregivers of critically ill patients can be partners in the early recognition, prevention and management of delirium provided they are aware of the signs/symptoms and appropriate non-pharmacological strategies that might be taken. Valid, reliable instruments that assess family caregiver knowledge are essential so that nurses can prepare family caregivers to be effective partners. The purpose of the current study was to (a) adapt an existing caregiver delirium knowledge questionnaire (CDKQ) for use by nurses to measure a family caregiver’s delirium knowledge in the ICU; and (b) examine the psychometric properties and structure of the adapted Caregiver ICU Delirium Knowledge Questionnaire (CIDKQ).

Methods

In this cross-sectional study, a multidisciplinary team developed the 21-item CIDKQ (possible score range: 0–21) and administered it to 158 family caregivers of critically ill patients. Descriptive statistics were examined for all variables. The CIDKQ was analyzed for face validity, content validity, reliability and internal consistency.

Results

The mean CIDKQ score was 14.1 (SD: 3.5, range = 2 to 21). Path analysis revealed that a family caregiver’s delirium knowledge in the actions and symptoms dimensions had a direct effect on knowledge of delirium risk factors. The CIDKQ was found to have face validity and reliability (Cronbach’s α = 0.79).

Conclusions

The findings indicated good validity and reliability of the CIDKQ as a measure of ICU delirium knowledge in family caregivers of critically ill patients.

Importance of families in care of individuals with mental disorders: nurses' attitudes

Abstract Objectives: To characterize the attitudes of nurses working in primary health care on the importance of involving families in nursing care to the person with mental disorder. Method: A cross - sectional descriptive study with a quantitative approach performed with 328 nurses who work in primary health care in Porto, Portugal. Families Importance in Nursing Care - Nurses Attitudes (FINC-NA) scale was applied. Results: Scale scores were elevated, mean value was 85.9 (Maximum possible 104). The significant correlations were with the variables: academic qualifications (p = 0.001), specialization (p = 0.002) and professional activity context (p = 0.001). Conclusion and implications for practice: Nurses demonstrate a high degree of agreement about the importance of families in nursing care to the person with mental disorder. Positive attitudes of nurses regarding the importance of involving families in care are fundamental to enhance the quality of care in the presence of mental disorder.

Searching for meaning: A grounded theory of family resilience in adult ICU

AIM

To explore families' experiences of their interactions in an Australian adult intensive care unit (ICU) to develop a grounded theory that can be used by critical care nurses to improve patient- and family-centred care (PFCC).

BACKGROUND

Families in ICU play an important role in the patient's recovery and outcomes. However, families are at risk of significant psychological morbidity due to their experiences in ICU. Although many ICU patients can make their own decisions, a large proportion are unconscious or chemically sedated and unable to contribute to decisions about their care, leaving the decision-making role to the family. Therefore, the families' psychosocial and emotional well-being must be supported by implementing evidence-based interventions that align with a PFCC approach. This study describes the findings of a grounded theory of family resilience in ICU, of which the core category is Regaining control. The focus of this paper is on the major category: Searching for meaning.

METHODS

We adopted a constructivist grounded theory method. Twenty-five adult family members (n = 25) of 21 patients admitted unexpectedly to an ICU in metropolitan Australia were recruited. In-depth interviews were used to collect the data, and the analytical processes of constructivist grounded theory underpinned the development of a core category and related subcategories.

RESULTS

When adult family members experience the unexpected admission of a relative to ICU, they move towards a state of being beyond emotional adversity and regaining control when facilitated to search for meaning in their situation. When families were able to make sense of their situation and find a purpose by contributing to their relative's recovery, it encouraged them to cope and be resilient.

CONCLUSIONS

Our findings can be used to promote PFCC in ICU, which considers a collaborative approach to meet the patient's needs while providing emotional and psychosocial support to their families.