How does a nursing crisis management intervention impact relatives' experiences in two trauma centres? A time-series study.

Background: Being a relative to a trauma patient may be a dramatic experience. Often, trauma centre nurses do not feel they have the competences needed to meet relatives experiencing a crisis. Therefore, a need exists to enhance their crisis management competencies. Objective: To investigate relatives' experiences of a nursing crisis management intervention on information, inclusion and support, including the importance of these needs in two Danish trauma centres. Design: A prospective intervention study based on interrupted time series. The intervention, conducted in 2020-2021, consisted of a crisis management training programme. Settings: The Trauma Centre of the Aarhus University Hospital and Aalborg University Hospital in Denmark. Participants: Relatives (18+ years) of critically ill or injured patients (n = 293). Methods: Data were collected using a 32-item questionnaire. The primary outcome was relatives' overall experience of the quality of the information, inclusion and support measured on a visual analogue scale (VAS) (0-10). Secondary outcomes were changes in risk ratios and scores between the periods for each of the three main variables. The outcome was measured as weighted and non-weighted scores, taking into account the importance of each variable. Besides use of interrupted time series, predictive and weight-adjusted analyses were performed. Time series comprised a before-period (6 months), an implementation period (3 months) and an after-period (6 months). Due to ceiling effect, the predictive analysis was dichotomized using the median scores for information, inclusion and support. Results: Overall, no differences were observed between the participants' characteristics in each of the three periods. Comparing the implementation period with the after-period revealed a statistically significant positive difference between the relatives' assessment of crisis management [p = 0.009]. Additionally, the probability of scoring >8 from before to after the intervention increased statistically significantly [Risk ratio 1.21, 95 % confidence interval 1.16-1.27]. The secondary outcomes showed that the greatest change over time was inclusion of relatives [Risk ratio, 1.25 95 % confidence interval 1.15-1.35]. Information had the greatest effect on relatives' experience of nurses' provision of crisis management and was also the needs area that relatives considered most important. However, information was also the needs area that evolved least during the study. Conclusions: Based on the selected cut-off levels, the intervention appeared to have a positive effect on relatives' experiences - especially inclusion of relatives. In the weighted analyses, information was considered most important and also had the greatest effect on relatives' overall experience. Nurses' crisis management competencies should be prioritized in trauma centres.

Frontline nurses' experiences of managing visitor restrictions during the COVID-19 pandemic in a Danish university hospital - Lessons learned.

BACKGROUND: Worldwide visitor restrictions forced nurses to separate patients from their relatives. However, the experience of implementing shifting restrictions from the frontline nurses' perspectives in a Danish context has yet to be assessed. AIM: The aim of this descriptive qualitative study was to explore frontline nurses' experiences of managing shifting visitor restrictions in a Danish somatic university hospital during the COVID-19 pandemic. METHODS: An online questionnaire, including open-ended questions, was developed. Data were analysed using descriptive statistics and content analysis. FINDINGS: 116 nurses from 29 departments participated; they were informed about restrictions primarily by their charge nurses and hospital intranet. Shifting visitor restrictions compelled the nurses to constantly adjust and negotiate their practices. When deciding to suggest deviating from the restrictions, they shared their decision-making with colleagues. Visitor restrictions left the hospital environment quieter, but they also created a lack of overview and predictability, an emotional burden, and a negative impact on the quality of care. CONCLUSION: Restricting relatives' access challenged the nurses' professional values, and it seems to have affirmed their appreciation of relatives' role as important partners in contemporary hospital-based health care.

Patient-physician conversations about life-sustaining treatment: Treatment preferences and participant assessments.

OBJECTIVE: In 2019, the Danish parliament issued legislation requiring Danish physicians to clarify and honor seriously ill patients' treatment preferences. The American POLST (Physician Orders for Life-Sustaining Treatment) document could be a valuable model for this process. The aim of the study was to examine patients' preferences for life-sustaining treatment and participant assessment of a Danish POLST form. METHODS: The study is a prospective intervention based on a pilot-tested Danish POLST form. Participant assessments were examined using questionnaire surveys. Patients with serious illness and/or frailty from seven hospital wards, two general practitioners, and four nursing homes were included. The patients and their physicians completed the POLST form based on a process of shared decision-making. RESULTS: A total of 95 patients (aged 41-95) participated. Hereof, 88% declined cardiopulmonary resuscitation, 83% preferred limited medical interventions or comfort care, and 74% did not require artificial nutrition. The preferences were similar within age groups, genders, and locations, but with a tendency toward younger patients being more in favor of full treatment and nursing home residents being more in favor of cardiopulmonary resuscitation. Questionnaire response rates were 69% (66/95) for patients, 79% (22/28) for physicians, and 31% (9/29) for nurses. Hereof, the majority of patients, physicians, and nurses found that the POLST form was usable for conversations and decision-making about life-sustaining treatment to either a high or very high degree. SIGNIFICANCE OF RESULTS: The majority of seriously ill patients did not want a resuscitation attempt and opted for selected treatments. The majority of participants found that the Danish POLST was usable for conversations and decisions about life-sustaining treatment to either a high or a very high degree, and that the POLST form facilitated an opportunity to openly discuss life-sustaining treatment.

Decision-making conversations for life-sustaining treatment with seriously ill patients using a Danish version of the US POLST: a qualitative study of patient and physician experiences.

OBJECTIVE: To explore patients' and physicians' perspectives on a decision-making conversation for life-sustaining treatment, based on the Danish model of the American Physician Orders for Life Sustaining Treatment (POLST) form. DESIGN: Semi-structured interviews following a conversation about preferences for life-sustaining treatment. SETTING: Danish hospitals, nursing homes, and general practitioners' clinics. SUBJECTS: Patients and physicians. MAIN OUTCOME MEASURES: Qualitative analyses of interview data. FINDINGS: After participating in a conversation about life-sustaining treatment using the Danish POLST form, a total of six patients and five physicians representing different settings and age groups participated in an interview about their experience of the process. Within the main research questions, six subthemes were identified: Timing, relatives are key persons, clarifying treatment preferences, documentation across settings, strengthening patient autonomy, and structure influences conversations. Most patients and physicians found having a conversation about levels of life-sustaining treatment valuable but also complicated due to the different levels of knowledge and attending to individual patient needs and medical necessities. Relatives were considered as key persons to ensure the understanding of the treatment trajectory and the ability to advocate for the patient in case of a medical crisis. The majority of participants found that the conversation strengthened patient autonomy. CONCLUSION: Patients and physicians found having a conversation about levels of life-sustaining treatment valuable, especially for strengthening patient autonomy. Relatives were considered key persons. The timing of the conversation and securing sufficient knowledge for shared decision-making were the main perceived challenges.KEY POINTSConversations about preferences for life-sustaining treatment are important, but not performed systematically.When planning a conversation about preferences for life-sustaining treatment, the timing of the conversation and the inclusion of relatives are key elements.Decision-making conversations can help patients feel in charge and less alone, and make it easier for health professionals to provide goal-concordant care.Using a model like the Danish POLST form may help to initiate, conduct and structure conversations about preferences for life-sustaining treatment.

Discussing patient preferences for levels of life-sustaining treatment: development and pilot testing of a Danish POLST form.

BACKGROUND: Medically frail and/or chronically ill patients are often admitted to Danish hospitals without documentation of patient preferences. This may lead to inappropriate care. Modelled on the American Physician Orders for Life-Sustaining Treatment (POLST) form, the purpose of the study was to develop and pilot test a Danish POLST form to ensure that patients' preferences for levels of life-sustaining treatment are known and documented. METHODS: The study was a mixed methods study. In the initial phase, a Danish POLST form was developed on the basis of literature and recommendations from the National POLST organisation in the US. A pilot test of the Danish POLST form was conducted in hospital wards, general practitioners' clinics, and nursing homes. Patients were eligible for inclusion if death was assessed as likely within 12 months. The patient and his/her physician engaged in a conversation where patient values, beliefs, goals for care, diagnosis, prognosis, and treatment alternatives were discussed. The POLST form was completed based on the patient's values and preferences. Family members and/or nursing staff could participate. Participants' assessments of the POLST form were evaluated using questionnaires, and in-depth interviews were conducted to explore experiences with the POLST form and the conversation. RESULTS: In total, 25 patients participated, 45 questionnaires were completed and 14 interviews were conducted. Most participants found the POLST form readable and understandable, and 93% found the POLST form usable to a high or very high degree for discussing preferences regarding life-sustaining treatment. Three themes emerged from the interviews: (a) an understandable document is essential for the conversation, (b) handling and discussing wishes, and (c) significance for the future. CONCLUSION: The Danish version of the POLST form is assessed by patients, families, physicians, and nurses as a useful model for obtaining and documenting Danish patients' preferences for life-sustaining treatment. However, this needs to be confirmed in a larger-scale study.

Family involvement in the intensive care unit in four Nordic countries.

BACKGROUND: Relevance to clinical practice The findings from the study highlighting family involvement, high-quality communication and flexible visiting policy as central aspects of family care may inspire clinicians to identify aspects of everyday family care in their ICUs calling for further improvement. AIMS AND OBJECTIVES: To describe family involvement, communication practices and visiting policies in adult ICUs. DESIGN: A cross-sectional survey. METHOD: A questionnaire consisting of 11 sections was developed, pilot tested and e-mailed to 196 ICUs. The participants were intensive care nurses in adult ICUs in four Nordic countries. RESULTS: The survey was conducted in October to December 2019. The response rate was 81% (158/196) of the invited ICUs. Most of the units had fewer than 11 beds. Family participation in patient care, including involvement in ward rounds and presence during cardiopulmonary resuscitation, varied between the countries, whereas most families in all countries were involved in decision-making. Family conferences were generally initiated by staff or family members. Children under 18 did not always receive information directly from the staff, and parents were not advised about how to inform their children. Although most respondents described open visiting, restrictions were also mentioned in free-text comments. CONCLUSIONS: The level of family care in ICUs in the four Nordic countries is generally based on nurses' discretion. Although most Nordic ICUs report having an open or flexible visiting policy, a wide range of potential restrictions still exists. Children and young relatives are not routinely followed up. Family members are included in communication and decision-making, whereas family involvement in daily care, ward rounds and family-witnessed resuscitation seem to be areas with a potential for improvement.

Conditions and strategies to meet the challenges imposed by the COVID-19-related visiting restrictions in the intensive care unit: A Scandinavian cross-sectional study.

OBJECTIVES: To examine conditions and strategies to meet the challenges imposed by the coronavirus disease 2019 (COVID-19)-related visiting restrictions in Scandinavian intensive care units. RESEARCH METHODOLOGY/DESIGN: A cross-sectional survey. SETTING: Adult intensive care units in Denmark, Norway and Sweden. MAIN OUTCOME MEASURES: Likert scale responses and free-text comments within six areas: capacity and staffing, visiting policies and access to the unit, information and conferences with relatives, written information, children as relatives and follow-up initiatives. RESULTS: The overall response rate was 53% (74/140 participating units). All intensive care units had planned for capacity extensions; the majority ranging between 11 and 30 extra beds. From March-June 2020, units had a mean maximum of 9.4 COVID-19 patients simultaneously. Allowing restricted visiting was more common in Denmark (52%) and Norway (61%) than in Sweden where visiting was mostly denied except for dying patients (68%), due to a particular increased number of COVID-19 patients. The restrictions forced nurses to compromise on their usual standards of family care. Numerous models for maintaining contact between relatives and patients were described. CONCLUSION: Visitation restrictions compromised the quality of family care and entailed dilemmas for healthcare professionals but also spurred initiatives to developing new ways of providing family care.

Identifying improvement opportunities for patient- and family-centered care in the ICU: Using qualitative methods to understand family perspectives.

PURPOSE: The purposes of the study were to provide richer context for families' quantitative assessments of the quality of ICU care, and to describe further quality areas of importance for family members. MATERIALS AND METHODS: Free-text comments from 1077 family members of 920 patients focusing on family evaluation of ICU quality of care were analyzed using content analysis. Twenty-one Danish and Dutch ICUs participated from October 2014 to June 2015. RESULTS: Four themes emerged as important to families: information, clinician skills, ICU environment, and discharge from the ICU. Families highlighted the importance of receiving information that was accessible, understandable and honest. They indicated that quality care was ensured by having clinicians who were both technically and interpersonally competent. The ICU environment and the circumstances of the transfer out of the ICU were described as contributing to quality of care. The comments identified room for improvement within all themes. CONCLUSIONS: The study highlights the importance of including both technical and emotional care for patients and families and the consequent need to focus on clinicians' mastery of interpersonal skills.

Post-ICU symptoms, consequences, and follow-up: an integrative review.

AIM: To determine the symptoms seen in patients after discharge from an intensive care unit (ICU) and the follow-up programmes offered to help patients deal with the problems that arise after an ICU stay. BACKGROUND: An increasing number of people are discharged from an ICU to continued treatment, care and rehabilitation in general hospital wards, rehabilitation facilities and at home. A prolonged stay in an ICU is associated with stressful memories that have long-term physical, mental and social consequences for health-related quality of life. We therefore conducted a data search to identify the programmes that have attempted to cope with these consequences. DATA SOURCES: Searches of six online databases were conducted in December 2013. REVIEW METHODS: Qualitative or quantitative, original, empirical studies on symptoms and consequences associated with ICU stay and the follow-up programmes offered were reviewed. Excluded were studies in ICU patients younger than 18 years published in languages other than Scandinavian or English. We analysed original empirical studies according to symptoms, consequences and follow-up programmes and added a category 'new ideas'. This was done to identify any possible evolution in the programmes offered to patients after ICU care. The review of the literature and the critical analysis were summarized in a figure in order to join the different parts together into a logical, coherent whole. CONCLUSIONS: Patients discharged from an ICU are heterogeneous, with a wide array of physical, mental and social problems. They and their close relatives can benefit from returning together to the ICU or participating in follow-up programmes. Little is known about the specific effects of the different types of follow-up. RELEVANCE TO CLINICAL PRACTICE: ICU staff as well as other professionals should prepare patients and relatives for the fact that they may need various types of help for many months after discharge from the ICU, and an overview of national and local opportunities for help should be offered.

From spouse to caregiver and back: a grounded theory study of post-intensive care unit spousal caregiving.

AIM: To explore the challenges and caring activities of spouses of intensive care unit survivors during the first year of patient recovery. BACKGROUND: Every year, millions of people globally are discharged from an intensive care unit after critical illness to continue treatment, care and rehabilitation in general hospital wards, rehabilitation facilities and at home. Consequently, millions of spouses become informal caregivers. Little is known, however, about the concrete challenges spouses face in post-intensive care unit everyday life. DESIGN: Explorative, qualitative grounded theory study. METHODS: Participants were spouses of intensive care unit survivors. The study was undertaken in Denmark in 2009-2010. Data consisted of 35 semi-structured dyad interviews at 3 and 12 months post-intensive care unit discharge, two group interviews with patients and two with spouses. FINDINGS: 'Shifting their role from spouse to caregiver and back' was identified as the core category of the study. The role shifts progressed in a dynamic process involving four elements: (1) committing to caregiving; (2) acquiring caregiving skills; (3) negotiating level of caregiving and (4) gradually leaving the caregiver role. Post-ICU caregiving comprised five patient dimensions: observing, assisting, coaching, advocating and managing activities. CONCLUSIONS: Spouses play a vital and multifaceted role in post-intensive care unit recovery. The findings can inform healthcare professionals in their efforts to prepare intensive care unit patients' families for the time following intensive care unit and hospital discharge. Hospital staff, rehabilitation experts and primary care professionals must acknowledge spouses' important contribution from intensive care unit admission throughout recovery.

Constructing the illness narrative: a grounded theory exploring patients' and relatives' use of intensive care diaries.

OBJECTIVE: After a stay in the intensive care unit, patients risk experiencing delusional memories, memory loss, and symptoms of posttraumatic stress. Since the 1990s, diaries have been kept for intensive care unit patients to help fill in memory gaps, aid psychosocial recovery, and improve health-related quality of life. More insight is needed into the application of diaries. The aim of our study was to explore how patients and relatives use diaries in the context of the illness trajectory. DESIGN: Qualitative multicentered design using in-depth semistructured interview technique. SETTING: A nine-bed general intensive care unit and a 13-bed thoracic surgical intensive care unit in Denmark. PATIENTS: A sample of 19 patients at 6-12 months postintensive care unit discharge and 13 relatives (n = 32). INTERVENTIONS: Intensive care diaries and handover 1 or 3 months postintensive care unit discharge. MEASUREMENTS AND MAIN RESULTS: Grounded theory method was used to explore the use of diaries as a psychosocial process of recovery involving patients and relatives. Data were managed by NVivo software. The core category was "constructing the illness narrative," which was a process of narration embedded in our emerging theory of psychosocial recovery after critical illness. The main categories within the patient perspective were information acquisition and gaining insight, and the main categories within the relative perspective were supporting the patient, supporting oneself, and negotiating access. CONCLUSIONS: Intensive care diaries are useful to patients as well as their relatives. Patients need to construct their illness narrative, and diaries are among the sources they use. The patients' project was to combine various sources of information in a process of information acquisition, narration, and evolving insight progressing toward recovery. The relatives supported the patients' project and also supported themselves by using the diary to uphold their own healing process. We recommend intensive care diaries as a low-technology, low-cost rehabilitative intervention for patients and relatives to help bridge the span from intensive care to recovery.

Flexible family visitation in the intensive care unit: nurses' decision-making.

AIMS AND OBJECTIVES: To identify and explore general strategies used by Danish intensive care unit nurses in everyday decision-making about family visitation. BACKGROUND: In the intensive care unit, relatives experience a strong commitment to watch over and protect the patient. Relatives can provide important help and support to their loved one. To do so, relatives need to be able to stay, preferably at the bedside. Managing a flexible visitation policy, nurses play an important role as gate-keepers at the bedside requiring strong discretionary power. Little is known about the rationale for nurses' decision making when allowing family members to stay by the patient's bedside or asking them to leave the unit. DESIGN: Explorative qualitative interview study. METHOD: In 2005 and 2008, we conducted a grounded theory study based on 11 semi-structured interviews with intensive care unit nurses. RESULTS: In the constantly shifting social context of the intensive care unit, nurses practiced clinical leadership balancing the needs of all parties involved, being mindful that the patient is their primary concern. To do so, they used three general strategies: Clarifying relations, Defining the situation and Guiding relatives in a concurrent and ongoing process, assessing when visiting is appropriate on a minute-to-minute basis. CONCLUSION: The study identifies and describes important professional considerations and values embedded in the nurses' decision making about visitation. Detailed knowledge in this area will provide a concrete basis for internal discussion on specific everyday interactions with visiting relatives, as well as more general discussions on the possibilities for and implications of enhancing flexible family visitation. RELEVANCE TO CLINICAL PRACTICE: To practice a contemporary visitation policy, the complexity of the task, the shifting context of the intensive care unit, the physical surroundings as well as possible limitations given by the staffing level should be acknowledged. The training of intensive care unit nurses should support adaptation to the clinical leadership role.

Interacting with relatives in intensive care unit. Nurses' perceptions of a challenging task.

AIMS: To describe how Danish intensive care unit (ICU)-nurses perceive personal knowledge and skills (self-efficacy) and outcome expectations to interacting with relatives. Moreover, to explore relationships between self-efficacy and outcome expectations and the nurses' attitude towards involving relatives in care-related tasks and allowing relatives to be with the patient during critical situations. BACKGROUND: Interacting with relatives can be a challenging task, and nurses play a leading role in integrating relatives in ICU. Little is known about how ICU-nurses cope with this part of nursing DESIGN: Cross-sectional METHOD: Sixty-eight ICU-nurses responded to a self-administered questionnaire based on Bandura's self-efficacy theory adjusted to critical care. RESULTS: The nurses' perceptions of personal knowledge, skills and expectations to the outcome of interacting with relatives were positive. There were disparities in nurses' level of agreement on when to involve relatives in caring activities. Generally, the nurses did not support the presence of relatives in critical situations. Nurses' outcome expectations were correlated to their attitude towards involving relatives in caring activities. No other statistically significant correlations were found between general attitude, knowledge, skills, and attitude of nurses towards involving relatives in caring activities or allowing them to be with the patient at cardiac arrest or acute intubation. CONCLUSION: The nurses' outcome expectations and self-efficacy in terms of knowledge and skills interacting with relatives were high. There was considerable variation in the nurses' agreement on when to involve relatives in caring activities or allowing them to be with the patient in critical situations. The self-efficacy theory was not supported as a result of lack of correlation between nurses' self-efficacy and outcome expectations and their attitude towards involving relatives in ICU. RELEVANCE TO CLINICAL PRACTICE: The study provides important knowledge to clinicians, educators and managers on how to educate and supervise ICU-nurses to support their efforts to interact proficiently with relatives.

Relatives' experiences in intensive care--finding a place in a world of uncertainty.

The aim of the study was to explore and describe the experiences of relatives of critically ill patients in adult intensive care. A qualitative research design was chosen, using a Grounded Theory approach. In-depth interviews were conducted with four spouses and three parents in a Danish University Hospital. An overall process of fitting in was apparent, explaining how relatives tried to manoeuvre in a chaotic and scary situation. The relatives were clearly in turmoil, yet found ways of coping in the situation and developing adaptation ability. Three major strategies were identified: enduring uncertainty, putting self aside and forming personal cues. This explorative study points to relatives being vulnerable and resourceful at the same time, struggling to find a place, experiencing distance from the patient as well as from the professionals and uncertainty regarding what to expect and how to act in the ICU. The study is a contribution to understanding relatives' needs and strategies and to developing better communication and cooperation between nurses and the patients' relatives.