Measuring gastric residual volume (GRV) to guide enteral feeding is a common nursing practice in intensive care units, yet little evidence supports this practice. In addition, this practice has been shown to potentially contribute to inadequate energy delivery in intensive care, which remains a problem in critically ill children.

We aimed to explore paediatric intensive care nurses' decision-making surrounding this practice.

This is a cross-sectional electronic survey in a single mixed general and cardiac surgical PICU in the UK.

The response rate was 59% (91/154), and responding nurses were experienced, with a mean PICU experience of 10·5 years (SD 8·09). The three main reasons for stopping or withholding enteral feeds were: the volume of GRV obtained (67%), the appearance of this gastric aspirate (40%) and the overall clinical condition of the child (23%). Most nurses reported checking GRV primarily to determine ‘feed tolerance’ (97%) as well as confirming feeding tube position (94%). Nurses' perceived harms from high GRV were: the risk of pulmonary aspiration (44%), malabsorption of feeds (20%) and the risk of vomiting (19%). GRV was measured frequently in this PICU, with 58% measuring GRV before every feed, 27% measuring every 4 h and 17% measuring every 6 h. The majority of nurses (84%) stated they would be worried or very worried if they could not measure GRV routinely.

PICU nurses' decision-making surrounding initiating and withholding enteral feeds and determining ‘feed tolerance’ remains heavily based on GRV. PICU nurses' have significant fears around patient harm if they do not measure GRV routinely.

This nursing practice is likely to be one of the factors that impair the delivery of enteral nutrition in critically ill children, and as such, its validity and usefulness needs to be challenged and studied in future research.

With improved survival rates in critical care, increasing focus is being placed on survivorship and how best to support patients in returning to their former activity. Little is known about what support patients themselves view as important, and this has implications for the efficacy and acceptability of services provided.

To describe former critical care patients' perspectives on the support needed to optimize recovery.

This is a qualitative exploratory study of the experiences of support received by critical care survivors.

Semi-structured interviews were undertaken with 12 critical care survivors recruited from a charity and a patient and public involvement group. The interviews were analysed using thematic analysis to describe patterns in the participants' experiences.

Four themes of support were described: effective management of transfer anxiety, tailored information provision, timely access to services and a supportive social network.

Survivors of critical care should be equipped with information about their critical care stay, ongoing health issues and recovery and should be provided with holistic care at home. Critical care follow up was an effective way of meeting many of these needs, but this needs to be flexible to be useful to attendees. Peer support groups (face-to-face and online) provided information, reassurance, a social network and an avenue for those who had longer-lasting problems than current services provide for.

Whilst there are commonalities in the problems faced by critical care survivors, recovery is highly individualized, and current support services do not have sufficient flexibility to cater for this. This study shows that many survivors experience after-effects of critical care that outlast the support they are given. These longer-term survivors are often excluded from research studies because of fears of recall bias, resulting in poor understanding of their experiences.

Physical restraint is mainly used in intensive care units (ICUs) to prevent delirious or agitated patients from removing tubes and lines connected to them. However, inappropriate use of physical restraint could have many detrimental physical effects on the patient, such as nerve damage, asphyxiation or even death.

The aim of the study is to investigate nurses' knowledge, attitude and practice of physical restraint in ICUs in Jordanian hospitals, about which little is known.

A descriptive and cross-sectional design was used.

A convenience sample of 400 nurses working in three public hospitals and one university-affiliated hospital from different geographical regions in Jordan was selected. An Arabic version of the Physical Restraint Questionnaire (PRQ) was used to collect the data.

A total of 300 completed questionnaires were returned, with a response rate of 75%. Of the total sample, 51% were males, 65.7% were from public hospitals and 80.3% held a bachelor's degree. The mean score in the knowledge section was 9.7 (SD =1.7) out of 15; in the attitude section, it was 24.7 (SD = 4.8) out of 33; and in the practice section, it was 30.9 (SD = 3.5) out of 42. Nurses who reported previous related education scored higher on the knowledge section (mean = 10.7; SD = 1.4) than nurses who reported no previous related education (mean = 9.1; SD = 1.6; p < .001). However, no significant differences between these categories were found in relation to attitude and practice.

The study demonstrated some lack of knowledge and unsafe practices regarding physical restraint in ICUs in Jordan. It suggests improving nurses' knowledge, attitude and practices through in-service education on best practice for physical restraint, developing policies/guidelines and providing adequate staff and equipment to maintain patient safety and prevent complications.

Conducting education programmes on physical restraint for ICU nurses and providing other preventive strategies are important in improving nurses' knowledge, attitude and practice.

To explore non-sedated mechanically ventilated patients' communication with nurses in the intensive care unit.

Mechanically ventilated patients are temporarily voiceless, making interpersonal communication complex. Both nurses and patients find communication challenging and may experience negative emotions when communication fails. In Nordic countries, sedation protocols have changed to light/non-sedation, resulting in more patients being conscious and more clinical practitioners experiencing communication difficulties.

The study was qualitative with a phenomenological-hermeneutic approach. Data were collected at two intensive care units in Denmark from January to April 2015.

Data collection consisted of interviews with patients, focus group interviews with nurses and field observations concerning nurse–patient communication. Data were analysed as one collective body of data using Ricoeur's theory of interpretation.

The main theme showed that communication is a movement between the two opposite feelings of comprehension and frustration. Sub-themes showed (1) the dynamics of power change when the patient is voiceless; (2) consciousness and voicelessness make caring difficult; and (3) the process of interpreting and structuring communication is situational.

These findings are important in nursing care and provide perspectives on the shift from communication towards comprehension and, thus, away from frustration. A non-sedation protocol is a major change in clinical practice in relation to communication. It requires a new way of thinking where communication becomes an integrated part of care, and the nurse has to be constantly alert and adjust his or her communication strategies to the patient's changing needs and communication ability.

Some nursing interventions may optimize communication: (1) systematic assessment of patients' communication; (2) education of nurses in Augmentative and Alternative Communication; (3) using communication tools when possible; and (4) securing time, continuity, empathy and patience in nursing care.

Fatigue and abnormalities in cardiovascular parameters are recognized as major problems for patients with acute coronary syndrome. Non-pharmacological nursing interventions are useful for controlling this fatigue and reducing patients' suffering during hospitalization.

The present study compared the effects of aromatherapy massage and reflexology on fatigue and cardiovascular parameters in older female patients with acute coronary syndrome.

This study was a randomized clinical trial.

The study was conducted with 135 older female patients with acute coronary syndrome who were hospitalized in a cardiac care unit in 2014. They were invited to participate in the study and then were randomly divided into three groups: ‘aromatherapy massage’, ‘reflexology’ and ‘control’. The fatigue severity and cardiovascular parameters were assessed using the Rhoten fatigue scale and a checklist. Measurements in the groups were performed before and immediately after the intervention. Data analysis was performed using descriptive and analytical statistics via the SPSS software.

Aromatherapy massage significantly decreased fatigue, systolic blood pressure, mean arterial pressure and O₂ saturation more than the reflexology intervention. However, reflexology reduced patients' heart rates more than an aromatherapy massage (P < 0·05). Moreover, no significant changes were observed in patients' diastolic blood pressures when compared to the control group (P = 0·37).

Implementation of both aromatherapy massage and reflexology has positive effects on the fatigue and cardiovascular parameters of patients with acute coronary syndrome. However, aromatherapy massage can be more beneficial to use as a supportive approach in coronary diseases.

The need for reducing fatigue in acute coronary syndrome (ACS) patients in a cardiac care unit is evident. The implementation of aromatherapy massage and reflexology had positive effects on patients' fatigue as related to both physical and mental health.

Delirium is a serious complication in patients in intensive care units. Previous surveys on delirium management in daily practice showed low adherence to published guidelines.

To evaluate delirium management in nurses and physicians working in intensive care units in German-speaking countries and to identify related differences between nurses and physicians.

The study used an open online survey with multiple-choice responses.

An invitation for participation was spread via journals and electronic resources using a snowball system. Apart from recording socio-demographical characteristics, the survey collected data on delirium assessment, delirium-related processes, non-pharmacological prevention and treatment and barriers for implementation. Differences between nurses and physicians were tested by Fisher's exact test with sequential Bonferroni correction.

The survey was conducted in autumn 2016, and 559 clinicians participated. More nurses than physicians reported screening for delirium. The majority of clinicians reported screening for delirium when this was suspected; more than 50% used validated instruments. Half of the clinicians had delirium-related structures implemented, such as two thirds reporting delirium-related processes. Most cited barriers were lack of time and missing knowledge about delirium and its assessment. With significant difference, physicians recommended more than nurses early removal of catheters and daily interprofessional goals for patients.

In German-speaking countries, assessment of delirium needs further improvement, leading to accurate assessment. Delirium-related structures and processes appear to be implemented widely, with only a few differences between nurses and physicians.

Nurses and physicians in this survey reported similar perceptions and attitudes towards management of delirium. Both professions need more knowledge and inter-professional training on when and how to use validated assessment instruments.

Delirium is highly prevalent within critical care and is linked to adverse clinical outcomes, increased mortality and impaired quality of life. Development of delirium is thought to be caused by multiple risk factors, including disruption of the circadian rhythm. Chronotherapeutic interventions, such as light therapy, music and use of eye shades, have been suggested as an option to improve circadian rhythm within intensive care units.

This review aims to answer the question: Can chronotherapy reduce the prevalence of delirium in adult patients in critical care?

This study is a systematic review of quantitative studies.

Six major electronic databases were searched, and a hand search was undertaken using selected key search terms. Research quality was assessed using the critical appraisal skills programme tools. The studies were critically appraised by both authors independently, and data were extracted. Four themes addressing the research question were identified and critically evaluated.

Six primary research articles that investigated different methods of chronotherapy were identified, and the results suggest that multi-component non-pharmacological interventions are the most effective for reducing the prevalence of delirium in critical care. The melatonergic agonist Ramelteon demonstrated statistically significant reductions in delirium; however, the reliability of the results in answering the review question was limited by the research design. The use of bright light therapy (BLT) and dynamic light application had mixed results, with issues with the research design and outcomes measured limiting the validity of the findings.

Multi-component non-pharmacological interventions, such as noise and light control, can reduce delirium in critical care, whereas other interventions, such as BLT, have mixed outcomes. Melatonin, as a drug, may be a useful alternative to sedative-hypnotics.

Chronotherapy can reduce the incidence of delirium within critical care, although further research is warranted. Staff education is essential in the implementation of chronotherapy.

In-hospital, family-witnessed cardiopulmonary resuscitation of adults has been found to help patients' family members deal with the short- and long-term emotional consequences of resuscitation. Because of its benefits, many national and international nursing and medical organizations officially recommend this practice. Research, however, shows that family-witnessed resuscitation is not widely implemented in clinical practice, and health care professionals generally do not favour this recommendation.

To describe and provide an initial basis for understanding health care professionals' views and perspectives regarding the implementation of an in-hospital, family-witnessed adult resuscitation practice in two European countries.

An inductive qualitative approach was used in this study.

Finnish (n = 93) and Polish (n = 75) emergency and intensive care nurses and physicians provided written responses to queries regarding their personal observations, concerns and comments about in-hospital, family-witnessed resuscitation of an adult. Data were analysed using inductive thematic analysis.

The study analysis yielded five themes characterizing health care professionals' main concerns regarding family-witnessed resuscitation: (1) family's horror, (2) disturbed workflow (3) no support for the family, (4) staff preparation and (5) situation-based decision.

Despite existing evidence revealing the positive influence of family-witnessed resuscitation on patients, relatives and cardiopulmonary resuscitation process, Finnish and Polish health care providers cited a number of personal and organizational barriers against this practice. The results of this study begin to examine reasons why family-witnessed resuscitation has not been widely implemented in practice. In order to successfully apply current evidence-based resuscitation guidelines, provider concerns need to be addressed through educational and organizational changes.

This study identified important implementation barriers for allowing families in critical care settings to be present during resuscitation efforts. These results can be further used in developing and adjusting clinical practice policies, protocols and guidelines related to family-witnessed resuscitation.

Men and women appear to exhibit different susceptibilities to sepsis and possibly divergent outcomes. However, the effect of sex and gender in critical illness outcomes is still controversial and the underlying mechanisms appear to be complex.

We aimed to systematically review and synthesize evidence on the influence of sex on outcomes in critically ill adult patients with sepsis, as reported in published studies specifically including investigation of the effect of sex among their aims. Primary outcome measures include in-hospital mortality, intensive care unit (ICU) mortality and length of stay (LOS) in the ICU.

The review was based on focused literature searches (CINAHL, PUBMED, EMBASE and COCHRANE). Methodological quality was assessed through the STROBE checklist and the Cochrane Tool for Bias in Cohort Studies. Meta-analysis was performed using STATA. Published observational studies addressing outcomes of sepsis among their primary aims and having included gender comparisons among primary outcomes in critically ill adult patients were included.

A total of eight eligible studies were included. With the exception of mortality, it was not possible to perform meta-analysis for other outcomes. Included studies reported data on 25,619 patients with sepsis (14 309 male/11 310 female). There is a paucity of well-designed studies addressing the effect of sex on mortality among patients with sepsis, and absence of studies addressing the effects of sex on multiple organ dysfunction of non-infectious origin. There was significant heterogeneity among study estimates (p = 0·001; I²=78·1%).

Although results of data syntheses appear to point towards a small disadvantage for survival among women, our results suggest that data on the impact of sex on sepsis outcomes remain equivocal. Implications for future research include approaches to adjustment for confounders and prospective designs.

Clarifying sex-related differences in sepsis, if any, is crucial for informing evidence-based care.

This research explores the current and potential future role of independent mental capacity advocates (IMCAs) in critical care. The Mental Capacity Act (MCA) of 2005 introduced IMCAs as advocates for patients without anyone to represent their best interests, but research suggests that this role is not well understood or implemented. No existing research explores the role of IMCAs in critical care or their potential use when families are judged ‘appropriate to act’ on the patient's behalf. It is suggested that families may not be best placed to advocate for their sick family member when they themselves are in a state of shock.

To investigate existing levels of knowledge and awareness of the MCA and understanding of the role of IMCAs in critical care as a prelude to considering whether the role of IMCAs might usefully be extended. The concept of ‘IMCA clinics’ is introduced and explored.

A small-scale qualitative study using thematic analysis of 15 interviews across two NHS sites and a survey of IMCA services were undertaken.

Some knowledge of the MCA was evident across both study sites, but training on MCA remains unsatisfactory, with confusion about the role of IMCAs and when they should become involved. Overall, participants felt that the broader involvement of IMCAs on a regular basis within critical care could be useful.

There was evidence of good practice when instructing IMCAs, but further work needs to be conducted to ensure that critical care staff are informed about the referral process. It was clear that expanding the role of an advocate warrants further investigation.

Further training on the role of IMCAs within critical care is required, and good practice examples should be shared with other units to improve referral rates to the IMCA service and ensure that vulnerable patients are properly represented.

Glycaemic control is recognized as one of the important aspects in managing critically ill patients. Both hyperglycaemia and hypoglycaemia independently increase the risk of patient mortality. Hence, the identification of optimal glycaemic control is of paramount importance in the management of critically ill patients.

The aim of this literature review is to examine the current status of glycaemic control in critically ill adult patients. This literature review will focus on randomized controlled trials comparing intensive insulin therapy to conventional insulin therapy, with an objective to identify optimal blood glucose level targets for critically ill adult patients.

A literature review was conducted to identify large randomized controlled trials for the optimal targeted blood glucose level for critically ill adult patients published since 2000. A total of eight studies fulfilled the selection criteria of this review.

With current human and technology resources, the results of the studies support commencing glycaemic control once the blood glucose level of critically ill patients reaches 10 mmol/L and maintaining this level between 8 mmol/L and 10 mmol/L.

This literature review provides a recommendation for targeting the optimal blood glucose level for critically ill patients within moderate blood glucose level target range (8–10 mmol/L). The need for uniformed glucometrics for unbiased reporting and further research for optimal blood glucose target is required, especially in light of new technological advancements in closed-loop insulin delivery and monitoring devices.

This literature review has revealed a need to call for consensus in the measurement and reporting of glycaemic control using standardized glucometrics.

Enteral nutrition is important in critically ill patients to improve patient outcomes, with nurses playing a pivotal role in the delivery and ongoing care of enteral nutrition. A significant deficit in nurses' knowledge and education relating to enteral nutrition has been identified, leading to iatrogenic malnutrition and potentially compromising patient care. Enteral nutrition appears to be prioritized lower than many other aspects of care. However, there is scant research to show how nurses prioritize enteral nutrition.

This study aimed to explore how nurses prioritize enteral nutrition when caring for a critically ill patient.

A descriptive online questionnaire, administered in May 2014, was utilized to explore the study aim. Descriptive statistics were performed to evaluate quantitative data. Content analysis was used to evaluate qualitative data.

A total of 359 responses were included in data analysis (response rate 20.8%). All respondents were registered nurses working within an Australian intensive care unit or high dependency unit. Nurses agreed that enteral nutrition was very important and should be commenced as soon as possible. However, life-saving procedures always took priority and there were often multiple barriers that hindered optimal delivery of enteral nutrition.

Respondents relied on their clinical judgement to inform decisions in relation to enteral nutrition in critically ill patients. Most respondents agreed that enteral nutrition was an important aspect of patient care, but acknowledged that other aspects of care were prioritized more highly. Despite this, some delays to enteral nutrition were perceived to be avoidable, and nurses recognized a need to advocate on the patient's behalf to increase the visibility of enteral nutrition.

The findings of this study demonstrate that enteral nutrition is often prioritized lower than other competing care needs in the critically ill patient. Given the importance of enteral nutrition to patient recovery, changes to clinical practice to improve enteral nutrition management are necessary.

Because of changes in sedation strategies, more patients in the intensive care unit (ICU) are conscious. Therefore, new and challenging tasks in nursing practice have emerged, which require a focus on the problems that patients experience. Thirst is one such major problem, arising because the mechanical ventilator prevents the patients from drinking when they have the urge to do so. To gain a deeper understanding of the patients' experiences and to contribute new knowledge in nursing care, this study focuses on the patients' experiences of thirst during mechanical ventilation (MV) while being conscious.

To explore patients' experience of thirst while being conscious and mechanically ventilated.

This hermeneutic study used qualitative interviews of 12 patients.

Data were analyzed based on content analysis. Interviews were conducted between September and October 2014 in two large ICUs in Denmark.

Four themes relating to the patients' experiences of thirst during MV were identified: a paramount thirst, a different sense in the mouth, deprivation of the opportunity to quench thirst and difficulties associated with thirst.

Patients associate feelings of desperation, anxiety and powerlessness with the experience of thirst. These feelings have a negative impact on their psychological well-being. A strategy in the ICU that includes no sedation for critically ill patients in need of MV introduces new demands on the nurses who must care for patients who are struggling with thirst.

This study shows that despite several practical attempts to relieve thirst, it remains a paramount problem for the patients. ICU nurses need to increase their focus on issues of thirst and dry mouth, which are two closely related issues for the patients. Communication may be a way to involve the patients, recognize and draw attention to their problem.

Family members of intensive care unit patients develop anxiety, depression and/or symptoms suggestive of risk for post-traumatic stress. Nurse-led support groups have been recommended and used in a variety of settings as a mechanism to help meet family needs and overcome challenges. These groups have been reported to increase the members' understanding of complex medical issues involved in their situations and to be helpful in identifying practical coping mechanisms.

To investigate the experiences of family members participating in a nurse-social worker led support group in the intensive care unit.

Study design: prospective collection of family narratives during support group meetings. A qualitative analysis was done of the narratives of weekly routine nurse-social worker led support group for family members of intensive care unit patients. The meeting contents are documented and related in the nursing notes.

Setting: level 1 trauma centre, at a university hospital, with 13-bed intensive care unit. During the past 3 years this family support group has been providing routine intervention with the purpose of calming the families of intensive care unit patients during crisis situations by utilizing nurse, social worker and group dynamics.

A qualitative analysis was performed on the content of support group dynamics. The principal themes found were Behavioural, Perceptual, Emotional and Supportive.

The family support group provides the participants with a ‘tool box’ of coping mechanisms, which they can choose from in this current unfamiliar crisis event. The group provides a supportive environment, mutuality, a sense of belonging, needs of community, unconditional acceptance and information provision for the participants in the group.

In order to provide support for several families, nurses can use the family support group intervention as an effective technique in reaching as many families as possible. Narratives from family members during group meetings may be a good information source providing insights for nursing guidance and patient/family education.

Quality of care is a major focus in the intensive care unit (ICU).

To describe a nurse-initiated quality improvement (QI) project that improved the care of critically ill patients in a New Zealand tertiary ICU.

A framework for QI was developed and implemented as part of a practice change initiative.

Audit data were collected, analysed and reported across seven nurse-influenced patient care standards. The seven standards were enteral nutrition delivered within 24 h of admission, timely administration of antibiotics, sedation holds for eligible patients, early mobilization and three pressure ulcer prevention strategies.

Comparison of audit data collected in 2014 and 2015 demonstrated improvements in five of the seven standards. Those standards with the largest practice improvements were related to the following standards: all eligible patients have enteral nutrition commenced within the first 24 h of ICU admission (3% increase); all eligible patients receive antibiotics within 30 min of prescription time (6% increase); all eligible patients have a daily sedation interruption (DSI; 24% increase); and all eligible patients are mobilized daily in their ICU stay (11% increase in percentage of patients mobilized daily).

The nursing-initiated QI project demonstrated improved ICU patient care in relation to early enteral nutrition commencement, DSIs and early and daily mobilizing.

The use of a nursing QI framework incorporating audit and feedback is one method of evaluating and enhancing the quality of care and improving patient outcomes. This initiative demonstrated the improved quality of nursing care for ICU patients, particularly in relation to early enteral nutrition commencement, timely antibiotics, DSIs and daily mobilizing. It is thus highly relevant to critical care nursing teams, particularly those working to create a culture where change is safe, achievable and valued.

The last decade has seen an increase in the number of centres able to provide venovenous extracorporeal membrane oxygenation (VV-ECMO) internationally across different health care systems. To support this growth, a variety of staffing arrangements have been adopted depending on local need and availability of resources, both in terms of manpower and finances to safely meet the complex needs of the patient and circuit management.

The aim of the survey was to describe current staffing arrangements of care provision for adult patients on VV-ECMO, with a focus on understanding the professional roles and responsibilities of staff managing the circuit in order to inform further discussion around different approaches to staffing.

We conducted a cross-sectional international survey using an electronic questionnaire emailed to 177 worldwide ECMO centres treating adult patients with acute respiratory failure. The survey questions were generated through an internal and external iterative process and assessed for clarity, content and face validity.

The response rate was 82%. Respondents managed extracorporeal oxygenation for adult respiratory alone (75%) or in combination with adult cardiac (67%), paediatric respiratory (62%) and paediatric cardiac (58%). The specialist nurse to patient ratio was 1:1 in 59% of centres, with 24-h/day presence in 74%. Overall, the specialist nurse provided the 24-h/day management of the circuit, including interventions. Perfusionists were responsible for the technical aspects of circuit management.

A specialist nurse with perfusion backup is the staffing arrangement implemented by most centres and likely reflects the most efficient use of the professional competences available.

Staffing for adult respiratory extracorporeal support has important implications for the planning of workforce, training and education, quality of service and the number of ECMO beds available.

Diaries written for patients in the intensive care unit (ICU) are offered in many European countries. In Austria, ICU diaries have been relatively unknown, but since 2012, they have started to emerge.

The aim of this study was to explore the extent and application of ICU diaries in Austria in 2015.

The study had a prospective multiple methods design of survey and interviews. All ICUs in Austria were surveyed in 2015 to identify which ICUs used diaries. ICUs using diaries were selected for semi-structured key-informant telephone interviews on the application of ICU diaries. Interviews were analysed by content analysis.

Of the 178 ICUs contacted, 13 had implemented ICU diaries. In all ICUs, diaries were sporadically introduced by a few dedicated nurses. Experiences of participating nurses can be summarized in two main themes: (a) the process of innovation and (b) the process of practice. Sub-themes were: (i) inspiration, creativity and innovation and (ii) purpose, indications, responsibility, authorship, experience, negative reception, and post-ICU practice. Individual nurses at each ICU found ways to organize and format ICU diaries while dealing with ambivalence and legal implications.

The implementation of a new nursing intervention is an ongoing process. Being innovative and responsible can be challenging, especially in hierarchical team structures. We recommend that nurses work towards national standards for the diary concept in order to enable future research into the process and outcome of ICU diaries.

The implementation of ICU diaries in routine care requires an ongoing adaptive, reflective process. Nurses may experience innovation, leading to the development of their own, feasible adaptions and structures.

Delirium in the intensive care unit (ICU) has received more attention in the past decade. Early detection, prevention and treatment of delirium are important, and the most commonly used tool for delirium assessment is the Confusion Assessment Method for the ICU (CAM-ICU).

The aim of this study was to identify nurses' and physicians' perceived professional barriers to using the CAM-ICU in Danish ICUs.

This study uses a qualitative explorative multicentre design using focus groups and a semi-structured interview guide. Five focus groups with nurses (n = 20) and four with physicians (n = 14) were conducted. Strategic sampling was used to include participants with varying CAM-ICU experience at units, with variable implementation of the tool.

Using a hermeneutical approach, three main themes and nine sub-themes emerged. The main themes were (1) Professional role issues: CAM-ICU screening affected nursing care, clinical judgment and professional integrity; (2) Instrument reliability: nurses and physicians expressed concerns about CAM-ICU assessment in non-sedated patients, patients with multi-organ failure or patients influenced by residual sedatives/opioids; and (3) Clinical consequence: after CAM-ICU assessment, physicians lacked evidence-based treatment options, and nurses lacked physician acknowledgment and guidelines for disclosing CAM-ICU results to patients.

In this study, ICU nurses and physicians raised a number of concerns regarding the use of the CAM-ICU for delirium detection. It might be necessary to revalidate the instrument as ICU care has changed in recent years, with lighter sedation and early mobilization of patients. We recommend that nurses and physicians receive more training in the use of the CAM-ICU to address some of the issues identified in our study.

There is a need for ongoing training and clearer guidelines on how to proceed with the delirium screening of non-sedated patients.

Nursing-sensitive indicators are considered effective tools for improving the quality of care in hospitals. However, these have not been used in paediatric intensive care units (PICUs) in China.

To develop nursing-sensitive indicators for PICUs and to assess the quality of nursing in PICUs in China based on the nursing-sensitive indicators.

Multi-centre, cross-sectional study.

Structure, process and outcome indicators were developed and measured from 1 January to 31 March 2014 in seven PICUs in China.

The structure indicators showed that one nurse cared for an average of 2·8 patients in a PICU, and 44% of nurses had a bachelor's degree. The process indicators revealed that hand-washing compliance varied across PICUs, whereas pain management and physical restraint have not been adequately addressed in China. The outcome indicators revealed that the incidence rates of ventilator-associated pneumonia and central-line-associated blood stream infections were 2·96 and 0·7, respectively, per 1000 device days. Patients were intubated for a total of 4392 mechanical ventilator days, and 32 patients (7·29‰) had an unplanned extubation. Nurses were moderately satisfied in their jobs (3·1 ± 0·3), and parents reported that nurses provide high quality of care.

This study developed and used nursing-sensitive indicators to assess the quality of nursing in PICUs in China, which provided a reference for national and international comparisons of nursing quality in PICUs. Nursing staffing levels and education should be improved. Pain management and physical restraints should be regulated in China's PICUs. Nurse managers need to explore staff attitudes towards implementation of family-centred care. The development of a national database of nursing quality indicators can contribute to quality and safety improvement.

This study developed a set of nursing-sensitive indicators, and these indicators were used to assess and improve the quality of nursing in PICUs.

Coronary heart disease has emerged as a number one killer in Malaysia and globally. Much of the morbidity and mortality in acute coronary syndrome patients is because of patients not recognizing their symptoms which contributes to delay in seeking early treatment.

The aim of this study is to evaluate the effectiveness of a nurse-led health education programme on knowledge, attitude and beliefs of coronary patients towards the responses to acute coronary syndrome and the association with patients' characteristics.

A single-group quasi-experimental design took place in a tertiary hospital. A total of 60 coronary patients were recruited to this study. The knowledge, attitude and beliefs towards acute coronary syndrome (ACS) were evaluated at baseline and after 1 month of giving education intervention.

Knowledge, attitude and beliefs about ACS increased significantly from baseline to 1 month after intervention. Level of attitude was associated with gender, educational level and employment status.

The findings of this study suggest that an education program conducted by a nurse improved patients' level of knowledge, attitudes and beliefs in response to ACS symptoms at 1 month compared to baseline, but whether they are sustained for a longer period is unclear. Improving the responses towards ACS might reduce decision delay in symptom interpretation and seeking early treatment.

Nurse-led interventions have imparted positive outcomes in response to ACS symptoms among coronary patients. Therefore, nurses should take the initiative in educating patients to minimize delay in symptom interpretation and seeking early treatment.

Systematic assessment of pain is necessary for adequate treatment of pain. Patient self-reported pain is a superior assessment but is of limited use for intubated patients in the intensive care unit. For these patients, the critical-care pain observation tool (CPOT) has been developed.

To perform a validation of the Dutch CPOT.

Cross-sectional observational study.

The Dutch translation of the CPOT was used. Clinimetric characteristics were analysed in a cross-sectional design. Internal consistency (Cronbach's alpha) was tested by collecting CPOT scores in patients at rest and during turning. Inter-rater reliability was tested by collecting CPOT scores simultaneously by two different nurses who were blinded to each other's scores. Criterion validity (area under the curve, sensitivity and specificity) of the Dutch CPOT (index test) was analysed using patient self-reported pain (reference test).

Cronbach's alpha was 0.56. During rest, the inter-rater reliability was 0.38 (95% confidence interval (CI): 0.20–0.53). During turning, the inter-rater reliability was 0.56 (95% CI: 0.42–0.68; area under the curve = 0.65 [95% CI 0.57–0.73]). At a threshold CPOT score of 2, the sensitivity and specificity were 39% and 85%, respectively.

The Dutch CPOT is available for pain assessment in intubated patients unable to self-report. Inter-rater reliability is moderate. At the threshold, a CPOT score of 2, the sensitivity was 39% and the specificity of 85%.

The CPOT is easy to use for systematic assessment of pain. Additional information about the threshold is valuable for use in daily practice.

Nurses' clinical autonomy is considered important for patients' outcome and influenced by the implementation approach of innovations. Emergent change approach with participation in the implementation process is thought to increase clinical autonomy. Planned change approach without this participation is thought not to increase clinical autonomy. Evidence of these effects on clinical autonomy is however limited.

To examine the changes in clinical autonomy and in personal norms and values for a planned change and emergent change implementation of an innovation, e.g. intensive insulin therapy.

Prospective comparative study with two geographically separated nurses' teams on one intensive care unit (ICU), randomly assigned to the experimental conditions.

Data were collected from March 2008 to January 2009. Pre-existing differences in perception of team and innovation characteristics were excluded using instruments based on the innovation contingency model. The Nursing Activity Scale was used to measure clinical autonomy. The Personal Values and Norms instrument was used to assess orientation towards nursing activities and the Team Learning Processes instrument to assess learning as a team.

Pre-implementation the measurements did not differ.

Post-implementation, clinical autonomy was increased in the emergent change team and decreased in the planned change team. The Personal Values and Norms instrument showed in the emergent change team a decreased hierarchic score and increased developmental and rational scores. In the planned change team the hierarchical and group scores were increased. Learning as a team did not differ between the teams.

In both teams there was a change in clinical autonomy and orientation towards nursing activities, in line with the experimental conditions. Emergent change implementation resulted in more clinical autonomy than planned change implementation.

If an innovation requires the nurses to make their own clinical decisions, an emergent change implementation should help to establish this clinical autonomy.

Patient falls are the most common adverse event in hospitals, resulting in devastating physical, psychological and financial consequences. Therefore the emphasis on falls assessment and prevention is a key priority. Within hospitals those reported at greatest risk of falls are older patients with little known about the factors within critical care. At a local level, a practice development project was identified to review risk factors contributing to falls in critical care.

To identify the incidence of falls within adult critical care and the risk factors most likely to contribute to a fall.

Reported falls incidents were reviewed retrospectively using a local incident reporting system, over a 2-year period from four critical care units.

Forty-two incidents were reviewed indicating a low rate of injury and low rate of occurrence (0·99 falls/1000 bed days). The median age of fallers was 58 years and the most common risk factor for falls was confusion or agitation, followed by patients attempting to mobilize against advice.

Critically ill patients were less likely to fall and were more likely to be younger than patients falling on an acute care ward. Neuroscience/trauma critically ill patients were more likely to fall than general critically ill patients; this was expected to be because of the increased presence of confusion or agitation in this group. The local system used to report falls produced difficulties in identifying risk factors in a consistent way. Although limitations exist, this review has enabled the development of more suitable local critical care falls risk factor assessment and interventions to minimize the risk of falling.

Fall rates, related injuries and circumstances of falls vary considerably among acute care and critical care specialities. Future work should concentrate on better falls reporting systems and further research should include validating risk factors for critical care falls.

Intensive care patients require a high frequency of blood testing, which results in a significant amount of blood loss. When blood is obtained from a central venous catheter (CVC), a large volume is usually discarded to obtain an unaltered sample for testing.

To determine the reliability of complete blood test results in blood samples obtained from the proximal lumen of a triple-lumen CVC using a 2-mL discard volume

Observational study with the prospective collection of data

The subjects enrolled were all patients with a subclavian triple-lumen CVC, older than 17 years and consecutively admitted to intensive care over a 2-year period. In each of the 54 participants, one blood sample was drawn from the proximal lumen of the catheter, discarding 1·61 mL of blood plus 0·39 mL of catheter deadspace (2 mL) and without interrupting infusion in the middle and distal lumens. A second sample was then obtained by direct venous puncture. The reliability of blood test results was determined by comparing sets of variables recorded for the two sampling methods through intraclass correlation coefficients in the Bland–Altman method.

Inter-method reliability for the variables examined was excellent, >0·75; range (0·868–0·998). Mean differences between the two sample types for the variables most often determined in critically ill patients were leukocytes: 0·200 × 10³/µL, 95% confidence interval (CI) (0·025 to 0·375); erythrocytes: 0·045 × 10⁶/uL, 95% CI (−0·003 to 0·094); sodium: 0·074 mEq/L, 95% CI (−0·369 to 0·517); potassium: −0·002mEq/L, 95% CI (−0·065 to 0·061) and glucose: 2·426 mg/dL, 95% CI (0·498–4·354).

The sampling method proposed minimizes blood loss while offering reliable blood test results.

The main benefit of the method proposed is reduced blood loss, improving the care of a critically ill patient.

The process of admission to an ICU may have a negative impact on a patient's physiological parameters and comfort.

To determine the effect of providing a patient admission protocol on patients' comfort and physiological parameters prior to admission to the intensive care unit (ICU).

A randomized, controlled experimental study.

This study included 100 (50 control, 50 experimental) patients who experienced planned admissions to the ICU of a University Hospital. Standard forms were used to record patient information, evaluations and comfort. Data were collected from patients prior to, during and 24 h after admission to the ICU and 24 h after being transferred. The experimental group was admitted to the ICU using the patient admission protocol and the control group underwent routine admittance.

There was no significant difference between the groups regarding the individual characteristics, physiology and comfort prior to, during or 24 h after admission to the ICU (p > 0·05). However, 24 h after being transferred, the experimental group's comfort was significantly higher than that of the control group (p < 0·01).

The use of the patient admission protocol does not affect the physiological parameters of patients; however, it does raise the comfort level of patients.

The patient admission protocol specific to the institution (in this context, a unit introductory booklet) should be developed in ICUs. We suggest that admission to the ICU should be carried out in accordance with this protocol.

The world's leading cause of preventable deaths, diseases and disabilities is smoking. Hospitalization can provide an opportunity for smokers to quit. Previous research found that smokers make up a high percentage of patients admitted to intensive care. Health care professionals working in critical care environments can make a valuable contribution to this public health issue by providing smoking cessation advice.

To identify factors that inhibit and facilitate the delivery of smoking cessation advice by nurses and doctors in critical care settings.

Quantitative design using an online survey.

This research was a single centre study carried out in a large tertiary hospital. Study sites were two adult critical care departments including a 14-bed general intensive care and a 16-bed cardiovascular intensive care unit. The target population for this research was the nursing and medical staff working in adult critical care environments.

The data suggests that doctors and nurses have a good understanding of the complications related to tobacco use and also have education on smoking cessation. Additionally the data suggest that doctors and nurses at the study sites generally have positive attitudes towards smoking cessation. Patient acuity and competence were concerns raised in relation to the delivery and effectiveness of smoking cessation advice in critical care environments.

The recovery phase following critical illness might be an opportunity to provide cessation advice. This could include focusing cessation advice efforts on awake, orientated and extubated patients. Further research might be required to confirm this.

The provision of smoking cessation advice is an on-going World Health Organization and New Zealand Government priority and all parts of the health sector need to provide responses. However, responses need to be adapted to the specific context such as the unique challenges of critical care.

Many patients lack a clear recollection from their stay in the intensive care unit (ICU). Diaries have been introduced as a tool to complete memories and reduce the risk of posttraumatic stress disorder (PTSD).

To describe and compare patients' memories and PTSD in relation to having received and read or not received a diary and patients' experiences of having received and read their diary, without having discussed the contents with ICU staff.

Descriptive and comparative.

Patients received their diaries at ICU discharge. After 2 months patients answered the ICU Memory Tool, a screening instrument for PTSD (PTSS-14) and a questionnaire including space for own comments about the diaries.

Of 96 patients, 52(54%) received a diary, 44 did not. Patients with diaries had significantly longer stay and more mechanical ventilation. Of these, 40 patients responded to PTSS-14 and had evaluated and read the diary and 34 patients served as controls. No significant differences were found in presence/absence of memories between these groups. In the diary-group patients with emotional memories had lower APACHE. Feelings of being anxious or frightened were more common in the diary-group. At 2 months, 12% scored above cut-off on the PTSS14 with no difference between groups. The diaries were helpful for understanding the ICU-stay.

Diaries seem valuable in understanding what happened, as an act of caring and as a tool for discussion with relatives and friends. Patients valued reading their diaries. None expressed the wish to have read the diary together with a member of staff. The diary and non-diary groups however reported similar memories.

Diaries seem to be valuable in understanding what happened, giving a feeling of trust and for talking about their ICU-stay. As many patients described stressful memories, sessions should be offered with ICU staff.

With ageing, older people face cardiovascular problems as the major cause of disability and death. Although immediate medical attention is a major factor in determining outcomes of cardiac problems, lack of personnel (i.e. registered nurse, certified nursing assistant and home care aide) in nursing homes without residing doctor limits the awareness of such problems, thus making it difficult to initiate timely and appropriate intervention.

The aim of this study was to conceptualize critical care for nursing home residents with cardiac vulnerability and develop practical knowledge in nursing practice.

Conventional content analysis was performed on date from interviews with 30 nurses from 10 nursing homes in South Korea between July and November 2010.

The analysis revealed three major cardiac problems resulting from residents' cardiac vulnerability: angina, myocardial infarction (MI) and cardiogenic shock. Through content analysis, we extracted 6 themes and 21 subthemes for nurses' conceptualization of critical care for nursing home residents with cardiac vulnerability. In nursing homes without a residing doctor, nurses assessed the physical, functional and cognitive conditions along with the responses and symptoms of residents when emergency situations related to the cardiac problems occurred. Moreover, with a lack of infrastructures of a hospital, nurses provided critical care to the elderly by using personal practice strategies based on their personal experience in facilities along with practical knowledge of nurses while following the management principles of emergencies.

We found that nurses conceptualized critical nursing care for cardiac problems at nursing homes, which are different from those of general hospitals. The results of this study will provide basis for the development of care guidelines and educational materials that can be used by novice nurses or nursing students.

Maintaining endotracheal tube patency is critical for neonates receiving mechanical ventilation. Endotracheal tube suctioning removes accumulated secretions preventing potential adverse events, however is also potentially hazardous to the patient.

To compare respiratory rate, arterial blood oxygen saturation, heart rate and pain in newborns undergoing endotracheal tube suctioning with closed (CS) and open (OS) systems.

Randomized crossover trial with 13 newborns from two Brazilian hospitals. The respiratory rate, arterial blood oxygen saturation, heart rate and pain (Premature Infant Pain Profile) were analysed: immediately before (T1), during (T2), immediately after (T3), 10 min after (T4) and 30 min (T5) after endotracheal suctioning.

The majority (11/85·0%) of the newborns were premature and 45% weighed less than 1000 g. No statistically significant difference was identified according to the use of CS or OS to all the parameters investigated. The main results demonstrated that in T2 arterial blood oxygen saturation was higher with CS (CS 93·0%; OS 89 · 0%; p = 0·561). In T3 there was an increase in respiratory rate average only with the use of OS (T1 50·0; T3 56·0). The pain score in T2 and heart rate in T3 were higher with OS without significant differences (p = 0·114; p = 0·479, respectively).

There was no significant difference in the studied clinical parameters or presence and intensity of pain according to the two investigated techniques of endotracheal tube suctioning.

This research can provide support for clinical practice regarding endotracheal tube suctioning of newborns describing that the use of closed systems was similar to the open system regarding pain presence and intensity, as well as, in the clinical effects analysed, in accordance with other studies produced in this field.

To describe patients' experiences of a follow-up visit to an intensive care unit (ICU) after being critically ill and nursed there.

Knowledge about the follow-up visit needs to be developed, with the previously critically ill patient in focus.

Qualitative descriptive.

Semi-structured interviews were conducted with nine patients and analysed using qualitative content analysis. The data collection occurred during spring 2014.

During the follow-up visits in ICU, the relatives, the patient diary, and those who took part in the care contribute to fill memory gaps to create a picture and an explanation of the care period.

The follow-up visit is an important tool in the patients' struggle to create a context and coherence from a missing or unreal time. The patient diary is essential to subsequently be able to relate to the period of care.

The follow-up visit, together with a personal diary, after an ICU stay could be seen as significant for strengthening the patients' feeling of coherence and better health.

Research exploring nurses' experiences working with families in paediatric intensive care unit (PICU) is limited. No studies have been undertaken in a mixed adult-paediatric ICU.

To explore nurses' perceptions of working with families of critically ill children in a mixed adult-paediatric intensive care unit (ICU).

Descriptive qualitative design.

Five PICU nurses participated in semi-structured interviews. Data were analysed using thematic analysis. Trustworthiness was enhanced using an audit trail, member checks and peer review of all data.

Three main themes and one overarching theme emerged. Role confusion and delineation examined the roles which nurses ascribed to themselves and the families; and demonstrated the conflict which could arise if roles were challenged. Information sharing demonstrated the positive and negative ways in which nurses utilized information with families in their daily practice. The contextual environment of the PICU scrutinized the physical, cultural and institutional factors which impacted on the nurses' ability to work with families in the PICU. Finally, the overarching theme Competing values explores the interplay between the nurses' personal values and those of the PICU and the institution.

Working with families in a mixed adult-paediatric ICU is influenced by multiple personal and institutional factors. The value placed on families and on the time nurses spent with them often competed for priority with nurses' other values and the wider culture of the PICU. The potential for role confusion, the management of information and the physical environment of the PICU further contributed to variability in nurses' working with families.

The results highlighted a need for education for both nurses and medical staff who work with families of critically ill children. Additionally, the need for each PICU to have a written policy on family presence and participation is crucial to guide practice and maintain continuity of care.

The needs of family members vary among cultures and hospitals. Often, these needs remain unmet increasing their stress and anxiety and decreasing their satisfaction with care, which may negatively impact the quality of patient care.

To assess the satisfaction of families with the care of their loved ones in critical care units (CCUs) in a large university medical centre in Lebanon and to assess the predictors of satisfaction.

A cross-sectional descriptive design was conducted using the Critical Care Family Satisfaction Survey (CCFSS). The participants were 123 adult relatives or significant others of patients cared for in both adult and paediatric intensive care units for at least 3 days.

The CCFSS showed acceptable internal reliability and construct validity in a Lebanese population. In general, families were satisfied with the care their loved ones received in the CCUs, and the least satisfaction was in the area of ‘comfort’ and the highest was in ‘assurance’. Younger family members with more education were less satisfied with care and Christian families expressed less satisfaction with informational needs compared with Muslim families. Families of children in the paediatric CCU expressed least satisfaction with care. Gender, residency, relationship to patient, unit, prior experience in a CCU and diagnosis had no effect on satisfaction scores.

Assessment of family satisfaction in different cultures is important as each culture has specific needs that are essential to decipher.

Patient satisfaction leads to improved quality of care; thus, it behoves nurses to meet the needs of families from different cultures to help them cope and increase their satisfaction, which leads to improve patient outcomes.

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.

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.

Searches of six online databases were conducted in December 2013.

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.

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.

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.

As many delirium manifestations (e.g., hallucinations or fears) are linked to patients' experiences and personality traits, it is suggested that interventions should be tailored to optimize its management. The inclusion of family members, as part of an intervention, has recently emerged as a solution to developing individualised patient care, but has never been assessed in post-cardiac surgery intensive care unit where almost half of patients will present with delirium.

To assess the feasibility, acceptability and preliminary efficacy of an nursing intervention involving family caregivers (FC) in delirium management following cardiac surgery.

A randomized pilot study.

A total of 30 patient/FC dyads were recruited and randomized to usual care (n = 14) or intervention (n = 16). The intervention was based on the Human Caring Theory, a mentoring model, and sources informing self-efficacy. It comprised seven planned encounters spread over 3 days between an intervention nurse and the FC, each including a 30-min visit at the patient's bedside. During this bedside visit, the FC used delirium management strategies, e.g. reorient the person with delirium. The primary indicator of acceptability was to obtain consent from 75% of approached FCs. The preliminary effect of the intervention on patient outcomes was assessed on (1) delirium severity using the Delirium Index, (2) occurrence of complications, such as falls, (3) length of postoperative hospital stay and (4) psycho-functional recovery using the Sickness Impact Profile. The preliminary effect on FC outcomes was assessed on FC anxiety and self-efficacy. Data were analysed using descriptive statistics, ANCOVAs and logistic regressions.

The primary indicator of obtaining consent from FC was achieved (77%). Of the 14 dyads, thirteen (93%) dyads received all seven encounters planned in the experimental intervention. Intervention group patients presented better psycho-functional recovery scores when compared with control group patients (p = 0·01). Mean delirium severity scores showed similar trajectories on days 1, 2 and 3 in both groups.

The mentoring intervention was acceptable and feasible and shows promising results in improving patients and FC outcomes.

Nurses should involve, if willing, FC to participate in activities that optimise patient well-being FC to use recognized delirium management strategies like reorientation and reassurance.

chronic critical illness (CCI) is a complex syndrome with a high risk of dying in hospital. Intensive care unit nurses are well-positioned to lead conversations integrating palliative and end-of-life care, yet have reported limited involvement.

To generate further understanding of nurses' experiences of patients with CCI and their families.

This qualitative study followed Thorne's interpretive description methods. In 2012, 16 intensive care unit nurses from one academic hospital participated in interviews.

Our primary theme was that of internal tension generated through participants' knowledge of patients' anticipated and protracted dying, while wanting to shield families from suffering. This internal tension resulted from responsibilities to preserve hope for patients and families, while at the same time wanting to provide them prognostic information. Participants experienced challenges of: (i) preserving family trust, (ii) determining when and how to engage families in discussions and (iii) providing possibilities of a ‘good’ death. A secondary theme described constraints to acting on their insights because of interprofessional team dynamics or limited communication, within the team and with the family.

Internal tension, as experienced by participants reflects the challenges of transition from acute to palliation and end-of-life care, made more complex in CCI, because of its poorly defined terminal stage. Nurses' ability to manage the complex process of supporting hope while gradually providing information to build family understanding of CCI highlights their central role in facilitating what and how prognostic information is given, while managing the emotional implications and family response. To better support nurses do this, we advocate for formal structures enabling nurses to participate in decision-making regarding timing of transitions using palliation and end-of-life care.

Inability to sleep is one of the most distressing factors for patients in the intensive care unit (ICU). Sleep is perceived as light and awakenings are numerous. Nurses' documentations of sleep are narrow, mainly concentrating on the quantity and general quality. Nurses should diversely evaluate, document and promote sleep to provide patient centered care.

To investigate the content of nurses' documentation about the sleep of ICU patients, patients' own perceptions of sleep, and the correspondence of the two.

Nurses' documentations (n = 90) were analysed retrospectively with quantitative content analysis. A cross-sectional survey of patients' (n = 114) perspectives was collected with the five-item Richards-Campbell Sleep Questionnaire (RCSQ), on a visual analogue scale from 0 (the poorest quality sleep) to 100 (optimum sleep). The data was analysed statistically. Correspondence was tested with cross-tabulation.

Nurses documented sleep quantity for 71% and quality for 27% of patients, along with the needs assessment, used interventions and their effect on sleep. Patients' perspectives varied widely. Sleep depth was rated the lowest and falling asleep highest of the RCSQ sleep domains. Age of the patients correlated positively with general quality of sleep, sleep depth and falling asleep. Nurses' documentations and patients' perceptions correlated in over half of the cases.

Nurses' documentation of ICU patients' sleep is not systematic or comprehensive and corresponds only partially with patients' own perception. The sleep of non-intubated patients is light and awakenings are frequent. Documentation of ICU patients' sleep should include the whole nursing process, i.e. needs assessment, interventions used, and evaluation of sleep and the effects of the interventions, along with patients' own perspective to promote patient-centered care.

Evaluation and documentation of patients' sleep must include patients' own perception to be comprehensive. Nurses' documentation should include all elements of nursing process.

The assessment of sleep quality in critically ill patients is a relevant factor of high-quality care. Despite the fact that sleep disturbances and insufficient sleep management contain an increased risk of severe morbidity for these patients, a translated and applicable instrument to evaluate sleep is not available for German-speaking intensive care settings.

This study aimed to translate the Richards Campbell Sleep Questionnaire (RCSQ), a simple and validated instrument eligible for measuring sleep quality in critically ill patients, and subsequently to evaluate the internal consistency of the German version of the RCSQ. Furthermore, it also aimed to inquire into the perception of sleep in a sample of critically ill patients.

The RCSQ was translated following established methodological standards. Data were collected cross-sectionally in a sample of 51 patients at 3 intensive care units at a university hospital in Germany.

The German version of the RCSQ showed an overall internal consistency (Cronbach's alpha) of 0·88. The mean of the RSCQ in the sample was 47·00 (SD ± 27·57). Depth of sleep was rated the lowest and falling asleep again the highest of the RCSQ sleep items.

The study demonstrated very good internal consistency of the German version of the RCSQ, allowing for its application in practice and research in German-speaking countries. Quality of sleep perception was generally low in this sample, emphasizing the need for enhanced care concepts regarding the sleep management of critically ill patients.

Relevance to clinical practice

Assessment of self-perception of sleep is crucial in order to plan an individually tailored care process.