Susanne Kean

Increased Hospital-Based Physical Rehabilitation and Information Provision After Intensive Care Unit Discharge: The RECOVER Randomized Clinical Trial

IMPORTANCE Critical illness results in disability and reduced health-related quality of life (HRQOL), but the optimum timing and components of rehabilitation are uncertain. OBJECTIVE To evaluate the effect of increasing physical and nutritional rehabilitation plus information delivered during the post-intensive care unit (ICU) acute hospital stay by dedicated rehabilitation assistants on subsequent mobility, HRQOL, and prevalent disabilities. DESIGN, SETTING, AND PARTICIPANTS A parallel group, randomized clinical trial with blinded outcome assessment at 2 hospitals in Edinburgh, Scotland, of 240 patients discharged from the ICU between December 1, 2010, and January 31, 2013, who required at least 48 hours of mechanical ventilation. Analysis for the primary outcome and other 3-month outcomes was performed between June and August 2013; for the 6- and 12-month outcomes and the health economic evaluation, between March and April 2014. INTERVENTIONS During the post-ICU hospital stay, both groups received physiotherapy and dietetic, occupational, and speech/language therapy, but patients in the intervention group received rehabilitation that typically increased the frequency of mobility and exercise therapies 2- to 3-fold, increased dietetic assessment and treatment, used individualized goal setting, and provided greater illness-specific information. Intervention group therapy was coordinated and delivered by a dedicated rehabilitation practitioner. MAIN OUTCOMES AND MEASURES The Rivermead Mobility Index (RMI) (range 0-15) at 3 months; higher scores indicate greater mobility. Secondary outcomes included HRQOL, psychological outcomes, self-reported symptoms, patient experience, and cost-effectiveness during a 12-month follow-up (completed in February 2014). RESULTS Median RMI at randomization was 3 (interquartile range [IQR], 1-6) and at 3 months was 13 (IQR, 10-14) for the intervention and usual care groups (mean difference, -0.2 [95% CI, -1.3 to 0.9; P = .71]). The HRQOL scores were unchanged by the intervention (mean difference in the Physical Component Summary score, -0.1 [95% CI, -3.3 to 3.1; P = .96]; and in the Mental Component Summary score, 0.2 [95% CI, -3.4 to 3.8; P = .91]). No differences were found for self-reported symptoms of fatigue, pain, appetite, joint stiffness, or breathlessness. Levels of anxiety, depression, and posttraumatic stress were similar, as were hand grip strength and the timed Up & Go test. No differences were found at the 6- or 12-month follow-up for any outcome measures. However, patients in the intervention group reported greater satisfaction with physiotherapy, nutritional support, coordination of care, and information provision. CONCLUSIONS AND RELEVANCE Post-ICU hospital-based rehabilitation, including increased physical and nutritional therapy plus information provision, did not improve physical recovery or HRQOL, but improved patient satisfaction with many aspects of recovery. TRIAL REGISTRATION isrctn.com Identifier: ISRCTN09412438.

Children and Young People Visiting an Adult Intensive Care Unit

AIM This paper is a report of a study into how children and young people constructed their experiences of visiting a critically ill family member in an intensive care unit. BACKGROUND Previous intensive care research has focused almost exclusively on adult family members, and so far children and young people have been excluded from family studies in this area. Consequently, very little is known about childrens and young peoples needs or their understanding when visiting an adult intensive care unit. METHOD Between 2002 and 2005, nine family interviews (12 adults and 12 children) were conducted. A constructivist grounded theory approach was employed in gathering and analysing data. FINDINGS The way in which children and young people discussed their intensive care visiting experiences suggest two different levels of understanding. Children tended to speak about intensive care on a concrete level, focusing on the environment (intensive care unit as environment). Young people, in contrast, understood their visiting experiences on an abstract level, focusing on the function of intensive care (intensive care unit as function). CONCLUSION A structured and age-appropriate approach to support children visiting an adult intensive care unit still needs to be developed. It is time for nurses to reflect on current practice, challenge beliefs and attitudes towards child visitation. Crucially, nurses need education in listening skills and understanding children and young peoples needs when an adult family member is in an intensive care unit. Further research is needed to develop appropriate support interventions and to investigate the importance and effects of intensive care unit visiting on children and young people.

Health Visitors as Family Nurses: A Discussion of Research, Policy and Practice in the United Kingdom

In the United Kingdom, a recent government consultative document (The Stationary Office, 1998) marked an increased political interest in supporting family well-being. Health visitors are targeted as a key service to promote and implement better family health. This article examines the perception of, and involvement in, families by health visitors as identified by an extensive review of the literature examining policy, practice, and existing research in health visiting. From this analysis, related areas requiring further research are identified.

Effects on oxygen saturation levels of handling premature infants within the concepts of kinaesthetic infant handling: pilot study

Preterm infants are exposed to many stressors within the neonatal intensive care environment. Since these are associated with medical and developmental problems, a reduction of stress factors is desirable. Handling is a very common occurrence and is associated with stress. Kinaesthetic infant handling (KIH) offers practical guidance on handling for nurses and has been widely implemented in Germany, although there is no direct experimental evidence to support its use. The findings of this pilot study suggest a beneficial effect on the SpO2 for infants who were handled using KIH. Since this was a pilot study with a small sample size, caution has to be exercised with this finding. Therefore, the main purpose of the study was: (1) to identify the weaknesses and strengths of the chosen study design; and (2) to perform a power analysis in order to determine a sufficient sample size for the full experiment.

A family intervention to reduce delirium in hospitalised ICU patients: A feasibility randomised controlled trial

BACKGROUND Family members could play an important role in preventing and reducing the development of delirium in Intensive Care Units (ICU) patients. This study sought to assess the feasibility of design and recruitment, and acceptability for family members and nurses of a family delivered intervention to reduce delirium in ICU patients. METHOD A single centre randomised controlled trial in an Australian medical/surgical ICU was conducted. Sixty-one family members were randomised (29 in intervention and 32 in non-intervention group). Following instructions, the intervention comprised the family members providing orientation or memory clues (family photographs, orientation to surroundings) to their relative each day. In addition, family members conducted sensory checks (vision and hearing with glasses and hearing aids); and therapeutic or cognitive stimulation (discussing family life, reminiscing) daily. Eleven ICU nurses were interviewed to gain insight into the feasibility and acceptability of implementing the intervention from their perspective. RESULTS Recruitment rate was 28% of eligible patients (recruited n=90, attrition n=1). Following instruction by the research nurse the family member delivered the intervention which was assessed to be feasible and acceptable by family members and nurses. Protocol adherence could be improved with alternative data collection methods. Nurses considered the activities acceptable. CONCLUSION The study was able to recruit, randomise and retain family member participants. Further strategies are required to assess intervention fidelity and improve data collection.

Editorial: Surviving critical illness: Intensive care and beyond

It is hard to convey just how debilitated one is after an insult of ICU magnitude. (Misak 2011, p 845). A healthcare policymaker once pointed out that an intensive care unit (ICU) patient is only an intensive care patient as long as this patient is in ICU – after that, this person becomes a patient wherever he or she is in the healthcare system. In essence, the special circumstances of ICU patients (if we accept that these patients do differ from the main hospital population) fade into the background. Why, however, should we pay special attention to ICU survivors? What is so special about this patient population? The first hint is entailed in the quotation at the beginning of this editorial of this special edition. Misak, a physician, experienced an episode of critical illness and draws attention to the magnitude of the debilitation she experienced postcritical illness. She describes the ‘persistent and overwhelming generalized weakness and fatigue’ (Misak 2011, p. 845) she experienced even eight months after hospital discharge. Naturally, being a healthcare professional, her explanations differ from most of our patients in that she has an understanding of the systematic muscle injury and loss that occurs as a consequence of critical illness. In my experience, most ICU survivors are surprised to learn that they lose muscle mass whilst in ICU and once explained immediately understand why they can’t do the same things they could before becoming critically ill or why it takes so long to recover. Importantly, Misak’s personal account of recovering from critical illness portrays some of the challenges ICU survivors face well beyond their discharge home. Understanding these challenges therefore has consequences in how clinical nurses care for ICU survivors across the recovery continuum. There is no doubt that past advances in pharmacology, medical technology and management of critical illness have resulted in increasing numbers of patients surviving critical illness. In fact, as Hillman (2007) pointed out, societal expectations are based on continuing rapid advances in all aspects of medicine including intensive care. However, no ICU patient survives if there is not skilled and professional nursing care that goes with those medical advances. For in reality, surviving a critical illness does come at a cost for patients and their families and nurses care for both at different times during this journey. In the past, costs and benefits of ICU treatment have been evaluated using ‘survival’ as an outcome measure (Young & Ridley 2002). Mortality rates were the guiding principle of success. Today, however, ‘we are in the middle of a real paradigm shift in our thinking about the scope and practices of critical care, and the continuum of a critical illness’ (Elliott 2011, p. 152). The research focus has shifted from simply surviving to the complexity of life postcritical illness. This shift is based on cumulating evidence that for some ICU survivors, critical illness leaves a legacy which is apparent in an array of physiological, psychological and emotional sequelae (Herridge 2007, Desai et al. 2011, Harvey & Davidson 2011). The challenges ICU survivors (and their families) face are many and wide ranging and include, to name a few, a lower health-related quality of life (Myhren et al. 2010), ICU-acquired weaknesses (neuromuscular dysfunction) (Herridge 2009, Griffiths 2010) and the very real impact this has on normal everyday activities such as walking, brushing hair or teeth and so on to the emotional and cognitive consequences of ICU (Rattray et al. 2010, Jackson et al. 2012), making sense out of delirium experiences in ICU (Samuelsona 2011) to the need of rebuilding one’s life after critical illness (Deacon 2012). What are noticeably absent at present are insights into the social aspects of life after critical illness. There is little research around this aspect, yet social factors such as being able to re-engage with a previous social life play an important part in enabling or impeding overall recovery. After all, we do not exist in a vacuum and our emotional and psychological well-being is also influenced by opportunities of participating in life and human interaction. As many ICU survivors who are affected by an ICU-acquired weakness will attest, going out of the house is a serious challenge because they simply lack the muscle mass and stamina to do so for quite some time postcritical illness. Consequently, this cohort experiences isolation at a time where (social) support is needed. In this context, families (understood here as a self-defined unit and therefore include close friends) are important in many ICU survivors recovery journey. Various Western countries around the world have seen or are seeing a shift in which health care is being shifted from the acute care into the community care sector at an ever earlier stage of the recovery process. This policy-driven change in healthcare delivery leaves many family members caring for what are essentially still very debilitated recovering ICU survivors. Whilst, in general terms, families constitute an under-researched group in ICU

Focus Group Interviews: A qualitative research approach for nursing

Focus Group interviews have become a popular technique for nursing research. This article introduces basic guidelines for the application of the methodology through a literature review and an example from nursing research. General and specific study design issues are covered.

Surviving critical illness

It is hard to convey just how debilitated one is after an insult of ICU magnitude. (Misak 2011, p 845). A healthcare policymaker once pointed out that an intensive care unit (ICU) patient is only an intensive care patient as long as this patient is in ICU – after that, this person becomes a patient wherever he or she is in the healthcare system. In essence, the special circumstances of ICU patients (if we accept that these patients do differ from the main hospital population) fade into the background. Why, however, should we pay special attention to ICU survivors? What is so special about this patient population? The first hint is entailed in the quotation at the beginning of this editorial of this special edition. Misak, a physician, experienced an episode of critical illness and draws attention to the magnitude of the debilitation she experienced postcritical illness. She describes the ‘persistent and overwhelming generalized weakness and fatigue’ (Misak 2011, p. 845) she experienced even eight months after hospital discharge. Naturally, being a healthcare professional, her explanations differ from most of our patients in that she has an understanding of the systematic muscle injury and loss that occurs as a consequence of critical illness. In my experience, most ICU survivors are surprised to learn that they lose muscle mass whilst in ICU and once explained immediately understand why they can’t do the same things they could before becoming critically ill or why it takes so long to recover. Importantly, Misak’s personal account of recovering from critical illness portrays some of the challenges ICU survivors face well beyond their discharge home. Understanding these challenges therefore has consequences in how clinical nurses care for ICU survivors across the recovery continuum. There is no doubt that past advances in pharmacology, medical technology and management of critical illness have resulted in increasing numbers of patients surviving critical illness. In fact, as Hillman (2007) pointed out, societal expectations are based on continuing rapid advances in all aspects of medicine including intensive care. However, no ICU patient survives if there is not skilled and professional nursing care that goes with those medical advances. For in reality, surviving a critical illness does come at a cost for patients and their families and nurses care for both at different times during this journey. In the past, costs and benefits of ICU treatment have been evaluated using ‘survival’ as an outcome measure (Young & Ridley 2002). Mortality rates were the guiding principle of success. Today, however, ‘we are in the middle of a real paradigm shift in our thinking about the scope and practices of critical care, and the continuum of a critical illness’ (Elliott 2011, p. 152). The research focus has shifted from simply surviving to the complexity of life postcritical illness. This shift is based on cumulating evidence that for some ICU survivors, critical illness leaves a legacy which is apparent in an array of physiological, psychological and emotional sequelae (Herridge 2007, Desai et al. 2011, Harvey & Davidson 2011). The challenges ICU survivors (and their families) face are many and wide ranging and include, to name a few, a lower health-related quality of life (Myhren et al. 2010), ICU-acquired weaknesses (neuromuscular dysfunction) (Herridge 2009, Griffiths 2010) and the very real impact this has on normal everyday activities such as walking, brushing hair or teeth and so on to the emotional and cognitive consequences of ICU (Rattray et al. 2010, Jackson et al. 2012), making sense out of delirium experiences in ICU (Samuelsona 2011) to the need of rebuilding one’s life after critical illness (Deacon 2012). What are noticeably absent at present are insights into the social aspects of life after critical illness. There is little research around this aspect, yet social factors such as being able to re-engage with a previous social life play an important part in enabling or impeding overall recovery. After all, we do not exist in a vacuum and our emotional and psychological well-being is also influenced by opportunities of participating in life and human interaction. As many ICU survivors who are affected by an ICU-acquired weakness will attest, going out of the house is a serious challenge because they simply lack the muscle mass and stamina to do so for quite some time postcritical illness. Consequently, this cohort experiences isolation at a time where (social) support is needed. In this context, families (understood here as a self-defined unit and therefore include close friends) are important in many ICU survivors recovery journey. Various Western countries around the world have seen or are seeing a shift in which health care is being shifted from the acute care into the community care sector at an ever earlier stage of the recovery process. This policy-driven change in healthcare delivery leaves many family members caring for what are essentially still very debilitated recovering ICU survivors. Whilst, in general terms, families constitute an under-researched group in ICU

Surviving critical illness: Intensive care and beyond

It is hard to convey just how debilitated one is after an insult of ICU magnitude. (Misak 2011, p 845). A healthcare policymaker once pointed out that an intensive care unit (ICU) patient is only an intensive care patient as long as this patient is in ICU – after that, this person becomes a patient wherever he or she is in the healthcare system. In essence, the special circumstances of ICU patients (if we accept that these patients do differ from the main hospital population) fade into the background. Why, however, should we pay special attention to ICU survivors? What is so special about this patient population? The first hint is entailed in the quotation at the beginning of this editorial of this special edition. Misak, a physician, experienced an episode of critical illness and draws attention to the magnitude of the debilitation she experienced postcritical illness. She describes the ‘persistent and overwhelming generalized weakness and fatigue’ (Misak 2011, p. 845) she experienced even eight months after hospital discharge. Naturally, being a healthcare professional, her explanations differ from most of our patients in that she has an understanding of the systematic muscle injury and loss that occurs as a consequence of critical illness. In my experience, most ICU survivors are surprised to learn that they lose muscle mass whilst in ICU and once explained immediately understand why they can’t do the same things they could before becoming critically ill or why it takes so long to recover. Importantly, Misak’s personal account of recovering from critical illness portrays some of the challenges ICU survivors face well beyond their discharge home. Understanding these challenges therefore has consequences in how clinical nurses care for ICU survivors across the recovery continuum. There is no doubt that past advances in pharmacology, medical technology and management of critical illness have resulted in increasing numbers of patients surviving critical illness. In fact, as Hillman (2007) pointed out, societal expectations are based on continuing rapid advances in all aspects of medicine including intensive care. However, no ICU patient survives if there is not skilled and professional nursing care that goes with those medical advances. For in reality, surviving a critical illness does come at a cost for patients and their families and nurses care for both at different times during this journey. In the past, costs and benefits of ICU treatment have been evaluated using ‘survival’ as an outcome measure (Young & Ridley 2002). Mortality rates were the guiding principle of success. Today, however, ‘we are in the middle of a real paradigm shift in our thinking about the scope and practices of critical care, and the continuum of a critical illness’ (Elliott 2011, p. 152). The research focus has shifted from simply surviving to the complexity of life postcritical illness. This shift is based on cumulating evidence that for some ICU survivors, critical illness leaves a legacy which is apparent in an array of physiological, psychological and emotional sequelae (Herridge 2007, Desai et al. 2011, Harvey & Davidson 2011). The challenges ICU survivors (and their families) face are many and wide ranging and include, to name a few, a lower health-related quality of life (Myhren et al. 2010), ICU-acquired weaknesses (neuromuscular dysfunction) (Herridge 2009, Griffiths 2010) and the very real impact this has on normal everyday activities such as walking, brushing hair or teeth and so on to the emotional and cognitive consequences of ICU (Rattray et al. 2010, Jackson et al. 2012), making sense out of delirium experiences in ICU (Samuelsona 2011) to the need of rebuilding one’s life after critical illness (Deacon 2012). What are noticeably absent at present are insights into the social aspects of life after critical illness. There is little research around this aspect, yet social factors such as being able to re-engage with a previous social life play an important part in enabling or impeding overall recovery. After all, we do not exist in a vacuum and our emotional and psychological well-being is also influenced by opportunities of participating in life and human interaction. As many ICU survivors who are affected by an ICU-acquired weakness will attest, going out of the house is a serious challenge because they simply lack the muscle mass and stamina to do so for quite some time postcritical illness. Consequently, this cohort experiences isolation at a time where (social) support is needed. In this context, families (understood here as a self-defined unit and therefore include close friends) are important in many ICU survivors recovery journey. Various Western countries around the world have seen or are seeing a shift in which health care is being shifted from the acute care into the community care sector at an ever earlier stage of the recovery process. This policy-driven change in healthcare delivery leaves many family members caring for what are essentially still very debilitated recovering ICU survivors. Whilst, in general terms, families constitute an under-researched group in ICU

First German Family Nursing Textbook

On its back cover, the publisher, Hans Huber, describes the book Familienbezogene Pflege as “a sound and practice oriented nursing book that focuses for the first time on families within the nursing care context.” Current political and professional changes in Germany (and Europe) underline the timely publication of this book. In June 2000, the second WHO (World Health Organization) Ministerial Conference on Nursing and Midwifery in Europe was held in Munich. In its closing declaration, ministers of health of member states in the European region declared tin the Munich Declaration (2000) that they