Nursing in critical careKeiko Mori, Miina Yamazaki, Yoshiyuki Haruna
BACKGROUND: Disasters increasingly challenge healthcare systems, highlighting the need to strengthen preparedness among future healthcare professionals. Although disaster risk awareness is important, it does not consistently translate into preparedness behaviours, reflecting the awareness-action gap. Immersive virtual reality (VR) may enhance experiential disaster learning, but how it influences preparedness processes remains insufficiently understood, particularly in healthcare and critical care education. AIMS: To explore how immersive VR-based disaster simulations influence disaster risk perception and preparedness among nursing students, with particular attention to the awareness-action gap and implications for future healthcare and critical care practice. STUDY DESIGN: A qualitative descriptive study using immersive VR-based disaster simulations followed by semi-structured interviews. Twelve undergraduate and graduate nursing students in Japan experienced immersive VR simulations depicting floods and landslides. Individual semi-structured interviews explored emotional responses, disaster risk perception, preparedness awareness and anticipated behavioural responses. Data were analysed using Krippendorff's content analysis with researcher triangulation. RESULTS: Five categories were identified: (1) heightened vulnerability and psychological burden through immersion; (2) persistence of the awareness-action gap despite increased risk perception; (3) enhanced risk recognition and preparedness intentions; (4) recognition of the need for social and structural support systems; and (5) emerging responsibility accompanied by perceived limitations. VR transformed abstract disaster risk into emotionally salient experiences, strengthening threat appraisal and preparedness awareness; however, awareness did not consistently translate into preparedness behaviours, reflecting insufficient coping appraisal and self-efficacy. CONCLUSIONS: Immersive VR may strengthen disaster risk perception and preparedness awareness, but immersive experiences alone may be insufficient to bridge the awareness-action gap. Combining VR with reflective learning, skills-based training and collaborative simulation may strengthen coping appraisal and preparedness action. RELEVANCE TO CLINICAL PRACTICE: Immersive VR combined with reflective and skills-based learning may support psychological readiness, situational awareness and disaster preparedness competencies among future nurses, including those preparing for critical care practice.
Nursing in critical careBruna Cristina Velozo, Aglecia Moda Vitoriano Budri, Larissa Cassiano Bernardo, Meire Cristina Novelli E Castro, Gabriela Dos Santos Cruz, Geovana Rodrigues Go…
BACKGROUND: The lack of consensus on the best pressure injury (PI) risk assessment tools demonstrates the need for further comparative research to identify the most effective options for intensive care unit (ICU) populations. AIM: This study compared the predictive validity and reliability of five PI risk assessment tools in adult ICU patients. STUDY DESIGN: A prospective cohort study was conducted with patients aged ≥ 18 years, admitted to the ICUs for at least 24 h and without pre-existing PI. Five tools (Braden Scale, CALCULATE, Cubbin & Jackson, EVARUCI and Sunderland) were used daily to assess PI risk until either a PI developed or the participant was discharged, died or completed 21 days in the ICUs. The main outcome measures included area under the receiver operating characteristic (ROC) curve, sensitivity, specificity, relative risk and reliability. RESULTS: Of the 150 participants, 40 (26.7%) developed PIs. None of the five tools demonstrated good predictive accuracy. AUC values ranged from 0.605 to 0.692 across the five tools, with none exceeding the predefined threshold of 0.70. Participants classified as high risk by Sunderland, Cubbin & Jackson and EVARUCI had a 3.0, 2.5 and 2.1 times higher risk, respectively, of developing a PI. Cubbin & Jackson was the only tool to achieve acceptable reliability values in Cronbach's alpha, intraclass correlation coefficient (ICC) and Cohen's weighted kappa. CONCLUSIONS: High-risk classification using the Sunderland, Cubbin & Jackson and EVARUCI scales was more strongly associated with subsequent PI development than classification using the other tools. Reliability findings varied across parameters, with Cubbin & Jackson being the only tool to meet acceptable thresholds across all assessed reliability measures. RELEVANCE TO CLINICAL PRACTICE: PI assessment in ICU patients should integrate validated tools with clinical judgement to address patient-specific and device-related risk factors.
Nursing in critical careRichard Kahalu, Joy Notter, Chris Carter
BACKGROUND: Critical care is an essential component of universal health care; however, its provision in low- and middle-income countries remains poorly understood. Although Zambia has expanded critical care services over the last 15 years, national evidence regarding workforce capacity, infrastructure and service provision remains limited. AIMS: To evaluate critical care workforce, service provision and patient case mix across Ministry of Health hospitals in Zambia. STUDY DESIGN: A cross-sectional survey was administered across 14 public hospitals with critical care units across Zambia, representing all 10 provinces. Data were collected via an e-survey questionnaire instrument. Descriptive statistical analysis was conducted using SPSS. Ethics approval was obtained prior to the study. RESULTS: All hospitals responded (n = 14/14, 100% response rate), accounting for a capacity of 131 critical care beds. Only 28.6% of hospitals had 24-h intensivist coverage, whereas all had registered critical care nurses. Equipment availability varied, with universal access to ventilators and monitors but limited access to syringe pumps and inconsistent availability of functional CT scanners. Over a 7-day period, 121 admissions were recorded, predominantly medical (29%), surgical (24.8%) and trauma-related (19.8%). Paediatric cases accounted for 40% of admissions. Formal admission and discharge protocols were present in fewer than half of the hospitals. CONCLUSION: The study provides the first national overview of public critical care provision in Zambia and provides a snapshot of current provision. The findings highlight urgent areas for capacity strengthening. RELEVANCE TO CLINICAL PRACTICE: Findings are similar to other studies within the sub-Saharan region and highlight the need to strengthen workforce training, particularly in critical and paediatric care, improve access to essential equipment and standardise care protocols to enhance patient safety and outcomes. The study demonstrates the importance of strengthening the multidisciplinary critical care workforce.
Septic shock complicated by acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS) presents a fundamental therapeutic conflict: shock demands aggressive fluid resuscitation, whereas lung protection requires fluid restriction and a negative fluid balance. We report the precision nursing management of a 79-year-old patient with septic shock, ARDS and MODS who received invasive mechanical ventilation and continuous renal replacement therapy (CRRT). A closed-loop 'monitoring-decision-intervention' strategy was built around electrical impedance tomography (EIT): EIT-guided positive end-expiratory pressure (PEEP) titration optimised respiratory support; during CRRT fluid management, continuous EIT monitoring of ventilation distribution provided early safety warnings regarding lung ventilation; EIT-based position titration established the 45° left lateral decubitus as the optimal ventilation position; real-time EIT imaging localised airway secretions to guide targeted postural drainage; and a prevention protocol for EIT electrode belt-related pressure injuries was implemented. After 10 days of intervention, the PaO2/FiO2 ratio increased from 150 to 356 mmHg, and the patient was successfully weaned and extubated. This case suggests that EIT-guided precision nursing may help balance fluid management with lung protection and provide visual guidance for airway clearance and position management; its effectiveness warrants validation in prospective studies. This case provides a reproducible, nurse-led framework that integrates EIT ventilation monitoring to reconcile competing treatment goals in septic shock complicated by ARDS, offering a practical reference for complex critical care nursing.
Acta anaesthesiologica ScandinavicaElisa Zoe Battistelli, Benjamin Skov Kaas-Hansen, Anders Granholm, Ronni Thermann Reitz Plovsing, Bodil Steen Rasmussen, Anders Perner, Maj-Brit Nørregaard Kjær
BACKGROUND: Patient-important outcomes beyond mortality, particularly health-related quality of life (HRQoL), are frequently used in intensive care unit (ICU) trials. However, HRQoL assessment remains challenging due to methodological complexities, including poorly defined recovery trajectories, lack of consensus on measurement instruments, complexity of statistical analysis, and missing data. Electronic patient-reported outcomes (ePROs) may improve data collection and efficiency, though their feasibility in ICU survivors is uncertain. METHODS: This protocol outlines a longitudinal, multicentre pilot study-within-a-trial aimed at evaluating the feasibility of ePRO-based HRQoL follow-up and exploring a trajectory-based approach to HRQoL characterisation after critical illness. We plan to enrol 100 participants already undergoing 180-day HRQoL follow-up in the Intensive Care Platform Trial (INCEPT) to complete monthly EQ-5D-5L surveys delivered by text messages from 6 to 12 months after randomisation. Feasibility outcomes include enrolment and response rate, time to completion, reminder-dependency, attrition pattern, agreement between modes of collection, and accessibility. Agreement between telephone- and ePRO-based assessments at 180 days will be evaluated at the group and at the individual level. Longitudinal EQ-5D-5L index values and visual analogue scale trajectories will be analysed using area-under-the-curve methods based on linear interpolation. Scenario-based sensitivity analyses will assess the potential impact of unobserved mortality among dropouts. DISCUSSION: We hypothesise that ePRO-based repeated assessments of HRQoL will support the goal of optimised data collection methods, while ensuring resources control. Moreover, identification of a candidate approach to HRQoL characterisation may shed light into the full recovery trajectory of ICU survivors and improve the interpretation and clinical relevance of HRQoL outcome assessments.
Nursing in critical careZahra Ahmed Sayed, Mohamed Ali Abdraboh, Eman Mohamed Ebrahim Abdelrazek
BACKGROUND: Early mobilisation is central to contemporary critical care, yet implementation remains inconsistent and ethically complex, particularly when patient safety, autonomy and resource constraints must be balanced. AIMS: To examine ICU nurses' perceptions of ethical concerns and implementation barriers related to early mobilisation in critically ill adults, including older adults, and their associations with professional characteristics. DESIGN: A single-centre analytical cross sectional study. METHODS: A convenience sample of ICU nurses completed a self-administered questionnaire comprising demographic and professional data and the researcher-developed Ethical Issues in Early Mobilisation-Critical Care Scale and Early Mobilisation Barriers Scale. Data were analysed using descriptive statistics, independent-samples t-tests, one-way analysis of variance, Pearson's correlation and multiple linear regression. RESULTS: A total of 100 ICU nurses participated in the study. The mean ethical-concern score was 113.41/150 (75.6% of the maximum possible score), and the mean barrier score was 69.94/90 (77.7%). Beneficence and Patient Well-being had the highest ethical-domain score. Patient-related barriers had the highest descriptive domain score, although all four barrier domains were closely distributed (76.6%-79.2%). Ethical-concern and barrier scores were modestly correlated (r = 0.292, 95% CI 0.103-0.461; p = 0.003), indicating limited shared variance. In mutually adjusted models, education level, ICU experience and previous early-mobilisation training were associated with both outcomes. The coded ICU-type term was associated with ethical-concern scores only, whereas professional nursing classification was associated with neither outcome. Age and gender were not associated with either score. CONCLUSIONS: Early mobilisation emerged as an ethical and organisational challenge, not merely a technical task. Ethical concerns and implementation barriers were related but largely distinct. Associations with education, ICU experience and training should be interpreted as correlational rather than causal. Integrated, context-sensitive approaches combining graded safety assessment, ethical decision-making, role clarity and organisational support warrant prospective evaluation. RELEVANCE TO CLINICAL PRACTICE: The findings support the development of evidence-based protocols, targeted educational initiatives and organisational strategies that strengthen nurses' clinical decision-making and facilitate the safe and consistent implementation of early mobilisation in critical care settings.
Nursing in critical careMarie O Collet, Camilla R L Bruun, Anders Granholm, Eva Laerkner, Anne C Brøchner, Annette L B Sørensen, Lone M Poulsen, Bodil S Rasmussen, Thomas Strøm, Anne-…
BACKGROUND: Patient and public involvement (PPI) is increasingly recommended in health research to enhance relevance, quality and implementation of findings. In intensive care research, involving patients, family members and healthcare professionals may help ensure that research addresses outcomes that are meaningful to those affected by critical illness. AIM: This study aimed to assess the level of meaningful PPI engagement during the development of a core outcome set (COS) for general intensive care unit (ICU) patients in Denmark. STUDY DESIGN: A cross-sectional survey using the Danish version of the Patient Engagement in Research Scale (PEIRS-22) was conducted between December 2024 and January 2025. We invited all members (patients, family, healthcare professionals and researchers) of five research panels, established in 2021 to support COS development across Danish university hospitals (N = 46). PEIRS-22 total scores range from 1 to 100, with higher scores indicating greater meaningful engagement (scores ≥ 70.1 were considered meaningful). Descriptive statistics, item-level analyses and non-parametric comparisons between participant roles were performed. RESULTS: Thirty-seven of 46 participants responded (80.4%): 27.0% (n = 10) were patients/family, 46.0% (n = 17) healthcare professionals and 27.0% (n = 10) researchers. The median PEIRS-22 total score was 78 (IQR 68-93), with 72.0% (n = 27) scoring ≥ 70.1. Engagement differed statistically significant by role (p = 0.004), with researchers reporting the highest scores (median 97), followed by patients/family (89), while healthcare professionals reported lower scores (74). CONCLUSION: PPI in COS development for general ICU patients was perceived as meaningful overall. However, differences across stakeholder groups and lower achievement of advanced engagement elements suggest opportunities to strengthen shared decision-making, role clarity and perceived relevance, particularly among healthcare professionals. Meaningful involvement of patients, families and clinicians may support the development of more patient-centred intensive care research and outcomes that better reflect the priorities of those affected by critical illness. RELEVANCE TO CLINICAL PRACTICE: Meaningful PPI can help ensure that intensive care research reflects the priorities of patients and families. Clear roles, clinical relevance, and opportunities to influence decisions may strengthen engagement, particularly among healthcare professionals. Critical care nurses may play an important role in facilitating collaboration between patients, families, clinicians, and researchers.
Nursing in critical careSayed Ibrahim Ali, Mostafa Shaban
BACKGROUND: Family caregivers often act as surrogate decision-makers for critically ill older adults, but little is known about how goals-of-care decisions are experienced in Saudi intensive care units, where family hierarchy, Islamic values, restricted visiting and physician-led communication shape care. AIM: To explore family caregivers' experiences of goals-of-care decision-making for critically ill older adults admitted to intensive care units in Al-Ahsa, Saudi Arabia. STUDY DESIGN: A qualitative study using reflexive thematic analysis. Semi-structured face-to-face interviews were conducted in Arabic with 18 purposively sampled family caregivers across three adult intensive care units in two government hospitals. Data were analysed inductively using Braun and Clarke's six-phase approach, supported by reflexive journaling and peer debriefing. FINDINGS: Four themes were developed: Navigating the Unknown; The Weight of an Impossible Responsibility; Faith as a Compass, Community as a Gaze; and Present but Unheard. Together, they describe compounding vulnerability created by informational opacity, moral responsibility, family hierarchy, diverse Islamic ethical interpretations, and inconsistent professional support. CONCLUSIONS: Goals-of-care decision-making in the participating Saudi intensive care units was emotionally demanding, culturally embedded and relationally mediated. Nurses were trusted relational anchors, but their supportive potential was constrained by workload and unclear formal roles. RELEVANCE TO CLINICAL PRACTICE: ICU nurses can support values-aligned decision-making through plain-language communication, inclusive engagement of both the family spokesperson and primary caregiver, culturally sensitive opportunities for marginalised caregivers to contribute and coordination of spiritual and psychosocial support.
Nursing in critical careKeiko Mori, Yasutaka Morita
Donation after brain death requires families to assume surrogate decision-making responsibility while coping with sudden loss and uncertainty. The aim of this study was to explore how family members became able to assume this responsibility. Semi-structured interviews were conducted 3-7 years after donation with four family members who had participated in organ donation discussions in Japan. Data were analysed using Krippendorff's qualitative content analysis. Families described being assigned responsibility before feeling ready, regaining orientation through sustained interaction with healthcare professionals, developing moral authorisation to decide despite uncertainty and integrating the decision into their lives over time. These findings suggest that surrogate decisional agency develops through relational and temporal processes rather than through information provision alone. Relational continuity, sensitive timing and post-decision support may help critical care nurses support families facing surrogate decision-making.
Nursing in critical careShaimaa Mohamed Amin, Ibrahim Alasqah, Mostafa Mohamed Zanaty, Sameer A Alkubati, Eman Yasser Hammouda, Mohamed H R Atta, Amira Abdelraheem, Suebsarn Ruksakulp…
BACKGROUND: Effective nursing handover is essential for ensuring patient safety and continuity of care, particularly in critical care settings where patients are highly complex and clinical decisions must be made rapidly. Occupational stress is prevalent among critical care nurses and has been associated with impaired performance and communication failures. Clinical decision-making is a core professional competency that may influence how stress affects handover quality; however, limited evidence has examined its combined effects. AIMS: To examine the impact of job stress and clinical decision-making on handover competency among critical care nurses and to test the mediating role of clinical decision-making in this relationship. STUDY DESIGN: A multicentre cross-sectional descriptive study was conducted in six hospitals in Egypt. Using a convenience sampling approach, participants completed self-administered, self-report questionnaires. Data were analysed using descriptive statistics, correlation analysis, multiple linear regression and mediation analysis with Hayes' PROCESS Macro (Model 4). RESULTS: A total of 410 critical care nurses were recruited for the study. They reported moderate levels of job stress, strong clinical decision-making abilities and high handover competency. Job stress was negatively correlated with both clinical decision-making (r = -0.242, p < 0.001) and handover competency (r = -0.218, p < 0.001), while clinical decision-making was positively correlated with handover competency (r = 0.332, p < 0.001). Regression analysis showed that higher educational level, rotating shifts and stronger clinical decision-making predicted higher handover competency, whereas higher job stress predicted lower competency. Mediation analysis revealed that clinical decision-making partially mediated the relationship between job stress and handover competency, with significant direct, indirect and total effects. CONCLUSIONS: Clinical decision-making plays a pivotal mediating role in the relationship between job stress and handover competency among critical care nurses. Job stress directly and indirectly impairs handover performance by diminishing nurses' decision-making capacity. RELEVANCE TO CLINICAL PRACTICE: Interventions aimed at reducing job stress and strengthening clinical decision-making, such as stress-management programs, simulation-based training and structured handover protocols, may enhance communication quality and patient safety in critical care settings.
Nursing in critical careFritz Sterr, Lydia Bauernfeind, Anja Kepplinger, Christian Rester, Rebecca Palm, Sabine Metzing
BACKGROUND: Weaning from mechanical ventilation appears to be a complex intervention as defined by the Medical Research Council Framework. However, there is a lack of theoretical insights into ventilator weaning, and the underlying causal mechanisms have not yet been uncovered sufficiently. To understand its complexity in theory and develop it in practice, a program theory is currently being developed in a multi-method study. AIM: To identify key characteristics and mechanisms in ventilator weaning of adult intensive care patients. STUDY DESIGN: In this sub-study, we conducted semi-structured group discussions and workshops with 29 healthcare professionals in intensive care over 3 days in 2025 in Germany, using a qualitative design. The data were collected using audio recordings, field notes and photographs. After transcription, a deductive-inductive thematic analysis was performed. FINDINGS: The analysis revealed four principal themes: (1) complexity of ventilator weaning, (2) outcomes, (3) interventions and (4) links and relationships. The first theme combines factors such as definition and delimitation, dynamics, structure and individualization, which together describe the inherent complexity. The second theme covers different endpoints during the process, including preconditions and postconditions as well as intermediate, immediate and ultimate outcomes. The third theme comprises direct and indirect interventions, as well as nonprogram external factors. The fourth theme explores the connections between interventions, outcomes and contextual factors. CONCLUSION: The findings of this study support the understanding that ventilator weaning is a complex intervention. The identified interaction of the various interventions, outcomes and contextual factors needs to be theoretically organized and evaluated in future studies. RELEVANCE TO CLINICAL PRACTICE: Identifying the interactions between key characteristics in this process can improve HCPs' sensitivity to the effects of their own actions. A theoretical understanding of the mechanisms underlying ventilator weaning enables the targeted development and evaluation of a complex weaning intervention. TRIAL REGISTRATION: Open Science Framework YGJ3T; https://doi.org/10.17605/OSF.IO/YGJ3T, registered on 14 May 2025.
BACKGROUND: Post-extubation dysphagia (PED) is common after invasive mechanical ventilation. Nurses can provide timely bedside risk screening, but instrument validity, performance in nurses' hands and implementation effectiveness are distinct questions. AIM: To map direct nurse-administered evidence, transferability of nurse-feasible tools, nursing implementation context, and reported patient outcomes in adult intensive care units (ICUs). METHODS: Literature searches were conducted in six databases, with the search updated in August 2026. Evidence was stratified according to the actual screening administrator and reference-standard assessment. Criterion-level MMAT and QUADAS-2 assessments were applied without summary scores. RESULTS: The source-verified map comprised 34 reports representing 31 study families. Instrumental-reference evidence with nurse or nursing-assistant administration included two complete-verification cohorts: modified Volume-Viscosity Swallow Test versus FEES in 44 extubated patients (sensitivity 89.5%, specificity 72%) and GUSS-IVA versus FEES in 51 of 56 enrolled patients (81.0%, 88.9%). A third nurse screen had optional FEES in 38 of 123 patients (86%, 21%). Other nurse-administered studies used clinical or proxy comparators or positive-only verification. SLP-administered FEES studies informed transferability, not nurse-administered accuracy. Implementation fidelity varied, and outcome studies were non-randomised. CONCLUSIONS: Nursing involvement in structured PED screening is feasible, but direct accuracy and patient-outcome evidence remain heterogeneous and at risk of selection, verification and confounding bias. ICUs may pilot governed pathways with competency assessment, documentation, specialist escalation and outcome audit; no single screen is established as standard care. RELEVANCE TO CLINICAL PRACTICE: Bedside screening is risk stratification rather than diagnosis. Failed, discordant or high-risk screens require prompt specialist assessment and, where indicated, FEES or VFSS.
Nursing in critical careTânia Filipa Almeida Machado, Inês Filipa Guerra da Silva, Natália Soares da Silva, Pedro Miguel Garcez Sardo
BACKGROUND: The Nursing Activities Score is a promising tool to calculate nursing workload in Intensive and Intermediate Care Units of different typologies. AIM: To assess nursing workload in a Stroke Unit using the Portuguese version of the Nursing Activities Score. STUDY DESIGN: Prospective observational study conducted with patients admitted to a Stroke Unit from November 2024 to February 2025. The study was approved by the Ethics Committee and was reported in accordance with the STROBE guidelines. RESULTS: The study included 69 patients admitted to the Stroke Unit for more than 24 h. Each participant generated an average nursing workload of 45.30 ± 7.39 points/day. The Stroke Unit recorded a median nursing workload of 159.40 (IQR: 126.60-211.90) points/day and an average occupancy rate of 82.0%. The days of admission and discharge are periods that tend to generate greatest nursing workload. There were statistically significant differences between the first and the last nursing workload assessments. Altered state of consciousness and fibrinolysis in the Stroke Unit are associated with greater nursing workload on the admission day. CONCLUSIONS: This study revealed the potential of the Nursing Activities Score as a tool to assess nursing workload in Intermediate Care Units, such as Stroke Units. The Nursing Activities Score showed an imbalance between nursing resources and reported care needs. The nursing workload was higher in the first assessment than in the last, reflecting the trend towards recovery of autonomy and improvement of the participants' clinical condition throughout the length of stay. There are demographic and clinical characteristics present at the time of admission that may be associated with a higher nursing workload. RELEVANCE TO CLINICAL PRACTICE: Nursing workload assessment using the Nursing Activities Score enables identification of patients and periods with the greatest care needs, thereby supporting decision-making in complex environments such as Stroke Units.
Acta anaesthesiologica ScandinavicaBenedikte Liebetrau, Andreas Ruhvald Madsen, Sören Möller, Markus Harboe Olsen, Sebastian Wiberg, Simon Mølstrøm
BACKGROUND: Intensive care unit (ICU) delirium is a multifactorial acute brain dysfunction associated with prolonged hospitalization, increased morbidity and mortality, and higher healthcare costs. Despite these substantial negative impacts of delirium, the optimal prevention and treatment strategies are unclear. Olanzapine, an atypical antipsychotic drug, is commonly used for delirium management. We will perform an updated systematic review and meta-analysis to assess the benefits and harms of olanzapine for the prevention and treatment of ICU delirium. METHODS: This protocol is developed in accordance with the recommendations of The Cochrane Collaboration and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) guidelines. We will include all randomized clinical trials (RCTs) evaluating prophylactic or therapeutic olanzapine versus any comparator, including pharmacological, non-pharmacological, placebo, or routine care/no specific delirium-directed intervention (treated as a single comparator) in ICU patients. Observational studies will be included solely to address potential harms. We will systematically search the following databases: Embase, MEDLINE, The Cochrane Library, Web of Science, CINAHL, Scopus, and PsycINFO, as well as clinical trial registries. We will perform meta-analysis and trial sequential analysis (TSA) to investigate the risk of both Type I and II errors. We will assess the risk of bias using the Cochrane Risk of Bias tool (RoB-2). The quality of trials will be evaluated using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. The review is registered in the PROSPERO database (CRD420261474813). OUTCOMES: The primary outcome is days alive and out of the hospital. The secondary outcomes include all-cause mortality at 90 days, number of CAM-ICU (Confusion Assessment Method for the Intensive Care Unit) negative days at 30 days, number of days without pharmacological treatment for delirium other than study drug during the intervention period and serious intervention-related harms. DISCUSSION: This protocol outlines the methodology we will use in a systematic review with meta-analysis designed to evaluate the beneficial and harmful effects of olanzapine for prevention and treatment of delirium in ICU patients. The findings of the systematic review will be disseminated through peer-reviewed publication. We hope this review will inform future RCTs and improve clinical practice.
Nursing in critical careMetin Tuncer, Cemal Özalp, Azra Keskin
BACKGROUND: Maintaining privacy in intensive care units (ICUs) is challenging because of high workload, invasive procedures, continuous monitoring and shared care environments. Patients with impaired consciousness may be particularly vulnerable because their ability to express privacy preferences, assert personal boundaries and advocate for themselves is limited. AIM: To explore intensive care nurses' experiences of protecting privacy when caring for patients with impaired consciousness. STUDY DESIGN: A descriptive qualitative study was conducted with 20 intensive care nurses in Türkiye between March and April 2026. Data were collected through semi-structured online interviews and analysed using inductive thematic analysis. The study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research guidelines. FINDINGS: Four themes were identified: the marginalisation of privacy under clinical priorities; structural and process-related constraints on privacy in intensive care; loss of subjectivity and the mechanisation of care in patients with impaired consciousness; and ethical and psychosocial implications of privacy violations. CONCLUSIONS: Privacy in intensive care is shaped not only by individual ethical awareness but also by workload, environmental conditions, care routines and communication practices. Patients with impaired consciousness have the same rights to privacy and dignity as other patients; however, their reduced ability to express preferences, assert personal boundaries and advocate for themselves may make privacy violations less visible and increase their dependence on nurses for protection. RELEVANCE TO CLINICAL PRACTICE: Protecting the privacy of patients with impaired consciousness in ICUs requires structured care routines, standardised bedside communication, minimisation of unnecessary exposure during procedures and targeted ethical awareness training to support dignity in everyday practice.
Nursing in critical careNana Wu, Xia Chen, Jie Fu, Liwen Ding, Hong Zhou, Tiantian Xiao
BACKGROUND: Point-of-care ultrasound (POCUS) is increasingly used in paediatric and neonatal critical care, but evidence on nurse-led bedside POCUS remains limited and fragmented. AIMS: This scoping review aimed to map the evidence on nurse-led bedside POCUS in paediatric and neonatal critical care nursing practice, examine implementation factors and identify evidence gaps relevant to nursing research, education and clinical practice. METHODS: Following JBI methodology and PRISMA-ScR guidance, we searched PubMed, Embase, CINAHL, Web of Science, Cochrane Library and CNKI from inception to October 2025. Eligibility followed the PCC framework. Two reviewers independently screened records and extracted data using a standardized form. Study characteristics were synthesized descriptively, and implementation factors were deductively analysed using the COM-B framework. RESULTS: Thirty-four studies were included, mainly from the United States and China. Nurse-led POCUS applications included vascular access, respiratory assessment, catheter localization, cardiac or hemodynamic evaluation, bladder assessment and education or competency development. Outcomes included clinical (procedural success and diagnostic accuracy), process (timeliness and workflow efficiency) and nurse-related (competency, confidence and role development). Safety-related outcomes were the least reported. Implementation was influenced by training, equipment, protected time, institutional support, collaboration and patient safety concerns. The automatic motivation domain, referring to unconscious drivers such as habits and emotional responses, was not addressed by any study. CONCLUSIONS: Nurse-led POCUS is an emerging but unevenly developed component of paediatric and neonatal critical care. Brief training may support initial competency, but sustained implementation is constrained by underdeveloped quality assurance, unclear career pathways and limited attention to motivational processes. RELEVANCE TO CLINICAL PRACTICE: Future nursing research and clinical programmes may look beyond short-term training outcomes to consider competency standards, longitudinal supervision, quality assurance, educational approaches combining foundational POCUS training with structured workplace supervision and sustainable integration into routine care delivery.
Nursing in critical careAyda Kebapcı, Begum Yalçın, Deniz Eşim, Gülşah Doğan, Şahika Mert
BACKGROUND: During the orientation process in the intensive care unit (ICU), the experiences and challenges of new nurses and their mentor nurses often differ, leading to potential incompatibilities. AIMS: This descriptive qualitative research aimed to determine the opinions and experiences of newly recruited nurses and their mentor nurses on the adaptation to the ICU. STUDY DESIGN: Semi-structured interviews were conducted with 21 nurses (10 mentors and 11 mentees) who worked in an ICU. Data were collected between March and May 2025. Four focus group interviews were conducted with mentors and mentees. Data were analysed using content analysis. Consolidated Criteria for Reporting Qualitative (COREQ) was used for reporting. FINDINGS: In the mentor group, three themes emerged: (1) mentor challenges in mentee conflicts, (2) helpful or harmful: a mentor's dilemma and (3) double duty: the rising workload of nurse mentors; in the mentees group, two themes emerged: (1) mentee challenges in mentor conflictsand (2) a good system with operational gaps. CONCLUSIONS: The study reveals the complex challenges faced by both new nurses and their mentors in the ICU. Although mentorship supports professional growth and patient safety, issues such as poor communication, mismatched expectations and emotional strain can hinder its effectiveness. These findings highlight the need to view mentorship as both an educational and an emotional process that requires mutual support. RELEVANCE TO CLINICAL PRACTICE: The study demonstrates that ICU mentorship must be recognized as a high-intensity clinical responsibility, requiring dedicated time to prevent mentor burnout and ensure patient safety. By addressing the identified communication gaps and 'double duty' burdens, healthcare managers can create a more resilient orientation system that improves the retention of newly recruited nurses.
Acta anaesthesiologica ScandinavicaEmma Larsson, Arman Valadkhani, Jesper Eriksson, Erik Svensk, Fredrik Hammarskjöld, Markus Castegren, Peter Bentzer, Nicklas Nielsen, Kristina Svennerholm, Mik…
BACKGROUND: Healthcare overuse, including unnecessary diagnostic testing and procedures, contributes to patient harm, increased healthcare costs, and resource waste. The Choosing Wisely initiative aims to reduce low-value care through evidence-based recommendations. However, limited evidence exists regarding the safety and effectiveness of implementing Choosing Wisely recommendations in intensive care settings. METHODS: The WICH-ICU is a registry-based stepped-wedge cluster randomized controlled trial designed to evaluate the implementation of specific Choosing Wisely interventions in Swedish intensive care units (ICUs). The study will include adult patients treated in participating Swedish ICUs. The intervention consists of three parts of the Choosing Wisely recommendations: (1) reduced frequency of arterial blood gas sampling, (2) reduced routine laboratory testing, and (3) reduced routine chest radiography. The primary outcome is 30-day mortality. Secondary outcomes include ICU length of stay, duration of mechanical ventilation (invasive and noninvasive), continuous renal replacement therapy duration, and ICU readmission within 72 h. Intervention data, testing intensity (arterial blood gas samples, laboratory tests, and chest radiographs per patient-day), will be collected through local monitoring, while outcome data will be obtained from the Swedish Intensive Care Registry (SIR). The stepped-wedge design allows each participating ICU to serve as its own control, with randomized timing of intervention implementation. DISCUSSION: This study will provide evidence on the safety and effectiveness of implementing Choosing Wisely recommendations in intensive care settings. The stepped-wedge cluster randomized design minimizes contamination while allowing all participating sites to eventually receive the intervention. The results will inform evidence-based de-implementation strategies in critical care. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT07013175.
European journal of psychotraumatologyShamini Satkunam, Irene Dimitriou, Madiha Shaikh
Background: Psychological morbidity is common following admission to adult intensive care units (ICUs), with many patients experiencing post-traumatic stress disorder (PTSD), anxiety, and depression as part of post-intensive care syndrome. Eye Movement Desensitisation and Reprocessing (EMDR) is an established trauma-focused psychological therapy; however, its evidence base within critical care populations remains emerging.Objectives: This scoping review aimed to map the extent, characteristics, and findings of the available literature on the use of EMDR for ICU-related psychological distress.Methods: A scoping review was conducted in accordance with Joanna Briggs Institute methodology and reported following the PRISMA-ScR guidelines. The review aimed to systematically identify and synthesise evidence relating to the application and reported outcomes of EMDR in ICU survivors.Results: Seven publications representing six independent study populations were included. Participants included adult ICU patients experiencing PTSD symptoms, delirium-related psychological disturbances, and COVID-19-related distress. EMDR was delivered using either standard protocols or the Recent Traumatic Episode Protocol (R-TEP). Across the evidence base, EMDR was associated with reductions in trauma-related distress, although evidence for improvements in anxiety and depression was less consistent. Where qualitative data were available, participants additionally reported improved integration and processing of ICU experiences. Overall, methodological heterogeneity, overlapping samples, small sample sizes, and limited controlled evidence restrict the strength of conclusions that can be drawn.Conclusions: This review highlights growing but preliminary evidence supporting the feasibility and potential utility of EMDR, including R-TEP, for ICU-related psychological distress. While findings are promising, the current evidence base remains insufficient to determine effectiveness. Future research should prioritise adequately powered controlled studies, standardised outcome measures, longer-term follow-up, and more diverse ICU populations to strengthen the evidence base and inform clinical implementation.
Giornale italiano di cardiologia (2006)Simona Giubilato, Francesca Musella, Carlotta Sorini Dini, Francesco Piroli, Nicola Gasparetto, Serena Guasti, Roberta Della Bona, Daniela Zabbia, Francesca Ca…
Point-of-care ultrasound (POCUS) is an imaging modality performed and interpreted by the treating physician at the bedside, with immediate integration of findings into clinical decision-making. Its rapid expansion in emergency medicine, critical care, and resource-limited settings has significantly improved diagnostic and therapeutic timeliness. However, this growth has highlighted the need to clearly define its scope of practice, standardize protocols, and distinguish POCUS from comprehensive consultative echocardiography. This review outlines the historical evolution of POCUS, from early trauma applications to structured protocols for shock, dyspnea, and cardiac arrest, and its current role in cardiopulmonary and hemodynamic monitoring of critically ill patients. Recent international guidelines are summarized, emphasizing POCUS as a distinct and complementary clinical tool rather than a replacement for formal imaging. Finally, future perspectives involving artificial intelligence and robotic ultrasound technologies are discussed, addressing their potential benefits and associated educational, organizational, and ethical challenges.
INTRODUCTION: In the past decade, the use of antidepressants in Iceland has increased rapidly. Given their widespread use, it is important to assess potential effects of SSRI/SNRI exposure during pregnancy on the newborn. The aim of this study was to examine the prevalence of SSRI/SNRI use at the time of delivery, the frequency of neonatal support or resuscitation, monitoring or admissions to the neonatal intensive care unit (NICU), and which clinical signs may possibly be linked to SSRI/SNRI exposure during pregnancy. METHODS: This was a retrospective comparative study, including all infants born at Landspítali in 2023 (n=3200). Infants born before 35 weeks of gestation were excluded. The study group consisted of infants whose mothers were on SSRI/SNRI treatment upon delivery, while the control group included all other infants in the study population. Additionally, infants admitted to the NICU were examined in more detail. RESULTS: Out of 3069 infants, 336 (10.9%) were exposed to SSRI/SNRI treatment during pregnancy. The need for neonatal support was significantly higher in the SSRI/SNRI group (29.2%) compared with controls (14.6%). Similarly, NICU admission or monitoring was more common (19.4% vs. 13%). Other significant differences included higher rates of respiratory distress, lower Apgar scores at 1 and 5 minutes, and more frequent sepsis work-ups in the SSRI/SNRI group. CONCLUSIONS: Infants exposed to maternal SSRI/SNRI treatment are more likely to require postnatal support, including oxygen therapy and respiratory assistance, as well as NICU care. Furthermore, these infants have lower Apgar scores at birth, and increased rate of sepsis work-up.
Nursing philosophy : an international journal for healthcare professionalsStelios Parissopoulos, Fiona Timmins, Marianna Mantzorou, George Tsakonitis, Meropi Mpouzika, Eleni Papagaroufali
This paper presents a focused analysis arising from a broader ethnographic study of nursing praxis, power relations, and clinical decision-making in a Greek ICU. The aim of this paper is to explore the morning bed-bath as a culturally embedded ICU nursing practice and to interpret how bodily care, professional identity, organisational routines and relational attentiveness intersect within this everyday activity. Informed by critical medical anthropology and phenomenology, the study draws on participant observation, ethnographic fieldnotes, and interviews with intensive care staff. The interpretation draws primarily on Foucault's concept of discipline, complemented by Bourdieu's notion of habitus and embodied practice, and Douglas's work on purity and symbolic order. Three interrelated themes emerged, forming a 'triptych of care': a) proximity and synchronicity to the patients' needs and clinical condition, which revealed skilled bodily attentiveness, clinical judgement and nursing agency, alongside negotiations of professional knowledge, and authority; b) the creation of a zone of safety and privacy, where bodily exposure, dignity, relational care, and professional interaction were negotiated within the ICU environment; and c) the removal of dirt and impurities, which served immediate clinical and hygienic purposes while also carrying cultural and professional meanings associated with bodily presentation, cleanliness, and order. The findings suggest that the morning bed-bath in the ICU studied was not merely a technical nursing task, but a culturally embedded and routinised practice through which temporal and organisational routines, embodied care, symbolic order, and professional nursing values are enacted.
Acta anaesthesiologica ScandinavicaAleksandra E Wlodarczyk-Abou Elseoud, Maija-Liisa Kalliomäki, Otto Mäkinen, Annika Laukkanen, Minna Bäcklund, Mitja Lääperi, Katri Hamunen, Anna-Maria Kuivalai…
BACKGROUND: A considerable proportion of patients in the intensive care unit (ICU) experience pain. The objective of this prospective observational cohort study was to investigate the prevalence of pain, factors associated with pain and pain trajectories in ICU patients. METHODS: Critically ill adult patients admitted to four ICUs across two tertiary university hospitals between 2018 and 2020 were recruited. Patients were followed during ICU stay for up to 14 days. Pain was measured using the Numeric Rating Scale (NRS), the Critical Care Pain Observation Tool (CPOT) and the Verbal Rating Scale (VRS). The primary outcome was the prevalence of at least moderate pain at rest defined as NRS ≥ 4, VRS ≥ moderate pain or CPOT ≥ 3. Risk factors for pain were analyzed with mixed effects logistic regression models. To enable a visual analysis of pain prevalence, a trajectory model was constructed based on pain assessment data. RESULTS: In total, 711 patients participated in the study. Most patients (76.4%) had at least moderate pain at some point during their ICU stay. Female sex, surgical reason for admission and opioids administered during ICU stay were all associated with increased odds for pain, whereas continuous sedation and a higher SAPS II score decreased the odds. The prevalence of at least moderate pain did not decline during ICU stay. CONCLUSION: The prevalence of at least moderate pain is relatively high in critically ill patients despite frequent use of opioids in the ICU. Identifying patients at risk for pain may aid in individualising pain management. EDITORIAL COMMENT: In this prospective study in a mixed adult ICU cohort, pain prevalence, character and trajectory is described. The majority of cases reported pain at rest, and case factors are presented.
Critical care nurseWei Jun Dan Ong, Eleanor Dela Peña, Faheem A Khan, Woon Hean Keenan Chong, Lawrence Ace Azul
BACKGROUND: Noninvasive ventilation is increasingly delivered outside intensive care units; however, ventilator alarm management, documentation, and competency validation remain inconsistent when paper-based processes are used. Delayed or inconsistent responses to actionable alarms may contribute to clinical deterioration and escalation of care. LOCAL PROBLEM: Nurses and respiratory therapists reported fragmented documentation, limited access to standardized troubleshooting guides, and time-consuming competency tracking for noninvasive ventilation devices in acute medical units that provide intermediate-level care. METHODS: This quality improvement project, which used a pre-post design, involved implementation of a digital ventilator safety workflow using QR code-linked alarm guidance and a secure online checklist. Data were collected during a 6-month baseline period and a 6-month postimplementation period. Clinical content, workflow mapping, and alarm-guidance pathways were developed in-house by the respiratory therapy department and deployed through AskVijay, a digital clinical guidance platform. Competency validation was conducted during onboarding and annual assessment. RESULTS: Digital implementation was associated with an increase in checklist completion compliance from 80% to 100% and a reduction in checklist completion time from a median of 8.5 minutes to 3.9 minutes. Use of required digital fields supported more complete documentation. Centralized electronic records enabled consolidated competency documentation and facilitated tracking of checklist and competency completion. CONCLUSION: A digital ventilator safety workflow supported standardized documentation, point-of-care access to alarm guidance, and competency tracking for unit-based noninvasive ventilation care. In-house clinical development enabled iterative refinement to align with local practice needs and workflows.
European journal of neurologyClément Caiazzo, Estelle Pruvost-Robieux, Ghazi Hmeydia, Eleonore Bouchereau, Camille Legouy, Charlotte Calligaris, Julie Lévi-Strauss, Catherine Oppenheim, Sa…
BACKGROUND: Management of lasting disorders of consciousness (DoC) is complex and sometimes requires referral of patients to an expert team. We aimed to evaluate the impact of such specialized expert assessment through the description of a single-center experience. METHOD: Monocentric study including all patients with DoC referred to a tertiary neuroICU for multimodal clinical, electrophysiological, and MRI assessment allowing diagnostic and therapeutic proposals and multidisciplinary prognostic prediction. The primary endpoint was the patients' actual outcome, assessed by 3-month functional disability and 1-year mortality, according to the predicted prognosis. RESULTS: Between July 2017 to June 2024, 124 patients (median age 61 [49-70] years, 67% of men) were referred from 43 departments of 37 primary hospitals. Most frequent etiologies were post-anoxic encephalopathy (62%) and secondary systemic brain injuries (15%). At a median of 23 [15-33] days after DoC onset, predicted prognosis was good in 20 (16%) patients, intermediate in 41 (33%), and poor in 63 (51%). Three-month GOS-E was 3 [1-3], 2 [1-3], and 1 [1] (p < 0.001) and 1-year mortality was 30%, 41%, and 82% (p < 0.001), respectively. Withdrawal of life-sustaining therapies increased with worsening predicted prognosis (38%, 41%, and 65%, respectively, p < 0.001), but functional disability and mortality remained higher in the poor prognosis group (p < 0.003 and p < 0.039, respectively) even after excluding patients with those decisions. CONCLUSION: Specialized consciousness assessment impacts the ethical decisions made by primary centers and helps refine the prediction of recovery but fails to achieve highly accurate individual prediction in a population with overall poor survival and functional prognosis.
Physiotherapy research international : the journal for researchers and clinicians in physical therapyPedro Vinicius Porfirio, Wagner Souza Leite, Layane Santana Pereira Costa, Pedro Henrique de Moura, Ana Célia Oliveira Dos Santos, Emanuel Fernandes Ferreira d…
OBJECTIVE: To map and synthesize methodological approaches used for ultrasound (US) assessment of peripheral (upper- and lower-limb) and abdominal muscle thickness in critically ill patients, and to propose a preliminary Standard Operating Procedure (SOP) as a structured reporting framework. METHODS: A review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist, using systematic searches on PubMed, BIREME (including MEDLINE, LILACS and IBECS) and Embase. Two reviewers independently screened, selected, and extracted data from studies published between 2015 and 2025. Extracted data included muscle groups assessed, thickness measurement criteria, patient and probe positioning, operational US parameters, and reliability information. The proposed SOP was developed based on recurring methodological patterns identified in the literature and subsequently refined through external expert review and pilot feasibility testing in ICU settings. RESULTS: Of 2.293 identified records, 29 studies (1.736 patients) were included. B-mode imaging and linear transducers were the most frequently reported US parameters, and the supine position with the head of the bed elevated to 30° was the predominant patient position. Although 79.3% of studies described muscle thickness measurement criteria, important methodological details such as depth, gain, and anatomical landmarks were inconsistently reported. Lower-limb muscles were the most frequently assessed, whereas upper-limb and abdominal muscles remained comparatively underrepresented. Considerable variability was identified across acquisition procedures, anatomical landmarks, measurement criteria, and reporting practices. CONCLUSIONS: Ultrasound assessment of muscle thickness in critically ill patients shows substantial methodological and reporting variability. A preliminary SOP was developed and pilot-tested to improve consistency and comparability. Standardization may support bedside monitoring and inform physiotherapy assessment and rehabilitation decisions, although multicenter validation is required. TRIAL REGISTRATION: Open Science Framework: https://doi.org/10.17605/OSF.IO/S95MJ.
Pediatrics in reviewChetna K Pande, Sarah Risen, Jessica M LaRosa, Sapna R Kudchadkar
As mortality from pediatric critical illness has declined, post intensive care syndrome in pediatrics (PICS-p) has emerged as a framework to describe the broad and often long-lasting morbidities experienced by survivors of pediatric critical illness. PICS-p encompasses new or worsening impairment in physical, cognitive, emotional, and social health that affect both the child and their family. The term PICS-p also acknowledges and reinforces the traumatic impact of the critical care on the child and family dyad. Given the growing population of pediatric survivors of critical illness and the limited availability of newly emerging, specialized post-critical care clinics, it is imperative that general pediatricians, providing the child's medical home, are equipped to diagnose and manage PICS-p in the outpatient setting. In this review, we summarize the prevalence, pathophysiology, clinical course, and impact of PICS-p on children and families. We also review preventive strategies that can be implemented in the PICU and conclude with practical guidance for general pediatricians caring for children after critical illness.
Nursing philosophy : an international journal for healthcare professionalsZhuanlian Li, Jiaqi You, Liuhua Zhang, Bangxing Ma, Yinhua Liu
Pain assessment in critical care is organised primarily around patient self-report and numerical scoring, an arrangement that protects the patient's first-person authority. In neurocritical care, however, critically ill patients with stroke may be unable to communicate because of aphasia, impaired consciousness, sedation, mechanical ventilation, or delirium. Under these conditions, the absence of a numerical score may reflect limitations in the systems through which pain is made visible rather than the absence of pain. This paper offers an empirically informed philosophical analysis of what a missing numerical pain score means in neurocritical care and asks how nursing can preserve clinically and ethically meaningful distinctions when a number cannot be responsibly produced. As an empirical point of departure, an extracted adult ischaemic-stroke ICU-stay dataset from MIMIC-IV (6054 ICU stays, 5065 patients) was used, focusing on the first pain score, defined as the earliest documented numerical pain score within the first 24 h after ICU admission among patients with stroke. The empirical material is treated not as epidemiological evidence but as an occasion for conceptual analysis. Of 6054 ICU stays, 2415 (39.9%) had no documented first pain score in the first-24-h structured field. This pattern is not interpreted as evidence that pain was absent, unassessed, or unrecognised in any individual case. Drawing on this finding, the paper develops a five-fold conceptual taxonomy of missingness: absence of pain, absence of self-report, absence of assessment, absence of documentation, and risk of non-recognition. Nursing management is presented as a moral-epistemic practice in which electronic record categories, quality indicators, staffing, education, and workflow shape whether possible pain becomes visible, documentable, auditable, and answerable. The central task is not to force every patient into a number, but to preserve clinically and ethically meaningful differences when a number cannot be responsibly produced.
Diving and hyperbaric medicineAlice Palmer, Craig Holdstock, Doug Watts, Rosanna J Stokes, Jack Whiteley
An experienced recreational diver developed a severe multisystem life-threatening decompression sickness following a series of eight dives over four days, the profiles of which were all within acceptable limits. The diver had marked haemoconcentration and required large volume intravenous fluid replacement during initial treatment. Similar presentations have previously only been described following deep dives, fast ascents or where mandatory decompression had been missed. The management of this case, including the involvement of a hyperbaric unit co-located to an intensive care department, and the underlying pathophysiology are discussed.
Dimensions of critical care nursing : DCCNMarziyeh Mohammadi, Mohammadreza Hashemian, Setayesh Sindarreh, Saeed Abbasi, Behjat Taheri
BACKGROUND: ICU nurses work in high-stakes environments where competence, defined as the integration of knowledge, skills, attitudes, values, and experience, is essential for ensuring patient safety, reducing mortality rates, and providing effective critical care. METHODS: Following the PRISMA 2020 guidelines, we searched critical care and nursing education journals in PubMed, Scopus, Web of Science, Embase, and CINAHL from 2015 to June 2025 for qualitative and quantitative studies on ICU nurse competence. The search strategy incorporated terms such as "educational frameworks for critical care education," "critical care nursing orientation," and "competency-based critical care nurse education." JBI tools were used to assess quality, and narrative synthesis was applied. RESULTS: Of the 1800 studies that were identified, 15 were included in the analysis. This analysis involved 2500 ICU nurses from 9 different countries. Competence is multidimensional. Facilitators such as simulation-based learning improve clinical decision-making, and ethical attitudes promote holistic care. Barriers include workloads that cause burnout and post-COVID infection gaps that lead to errors. Competence levels are high for clinical skills but low for research and family-centered care. Novices struggle in complex ICUs. CONCLUSIONS: This review suggests that combining the adoption of standardized, competency-based frameworks, particularly the AACN Synergy Model and the 2021 AACN Essentials, with objective, simulation-enhanced assessment tools can effectively address identified gaps and improve the competence of ICU nurses worldwide.
Dimensions of critical care nursing : DCCNGiovanni Gazzeri, Riccardo C Piccione, Chiara Gentini, Giovanni Cianchi, Manuela Bonizzoli
OBJECTIVES: To evaluate the perceived competence, clinical experience and training needs of Italian nurses involved in ECMO patient care. METHODS: A cross-sectional survey was conducted in 12 accredited ECMO centers across Italy, targeting ICU nurses with at least 6 months of ECMO experience. The questionnaire assessed perceived competence, procedural exposure, emergency preparedness, nontechnical skills, and training background. RESULTS: Among 162 respondents, most reported adequate perceived competence regarding ECMO indications and monitoring. However, practical experience with procedures such as cannulation, circuit change, and interhospital transfer was limited. Confidence in managing emergencies without immediate perfusionist support was low. Preferred training modalities included simulation and on-the-job coaching. Nontechnical skills such as teamwork and critical thinking were widely recognized as essential. CONCLUSIONS: The study reveals a substantial gap between perceived theoretical competence and practical readiness among ECMO nurses in Italy. Training variability and lack of formal curricular structures contribute to limited preparedness, especially for emergency management. IMPLICATIONS FOR CLINICAL PRACTICE: Standardized, simulation-based training programs should be implemented nationally to improve ECMO nursing competence, focusing on emergency scenarios and nontechnical skills. Establishing certification pathways may enhance professional recognition and safety in ECMO care.
BACKGROUND: Delirium prevalence in the intensive care unit (ICU) is high. Intensive nursing interventions have been performed to reduce delirium in ICU patients. There is now a wide variety of intensive nursing interventions available for treating delirium. However, the optimal intervention remains unknown. This systematic review and network meta-analysis (NMA) aimed to compare the efficacy of intensive nursing interventions in patients with delirium. METHODS: We included randomized controlled trials of different intensive nursing interventions for delirium in the ICU. A Bayesian NMA was conducted to evaluate the efficacy of various types of intensive nursing interventions. The outcomes assessed were the cure rate, intensive care delirium screening checklist (ICDSC) scores, and acute physiologic assessment and chronic health evaluation II (APACHE II) scores for different treatments. RESULTS: This meta-analysis included 21 studies. We analyzed a total of 5 different intensive nursing interventions: auricular points acupressure, music therapy, cognitive function exercise, regular nursing, increasing visiting hours, and targeted nursing. When compared with regular nursing, the other 5 intensive nursing interventions showed no significant difference in cure rate, ICDSC, and APACHE II scores (P > .05). Auricular points acupressure had the highest surface under the cumulative ranking area value for cure rate and APACHE II, indicating it ranked first in these outcomes. Music therapy demonstrated the most favorable effect on reducing ICDSC, with music therapy ranking first in this regard. CONCLUSION: This NMA suggests that auricular points acupressure might be the optimal intervention for increasing the cure rate and decreasing ICDSC and APACHE II scores in ICU patients with delirium. However, the surface under the cumulative ranking area values reflect relative ranking rather than absolute efficacy, and no intervention demonstrated statistically significant superiority over regular nursing. Additionally, increasing visiting hours appears to hold promise as an effective intervention for reducing delirium in the ICU. Further research and larger studies are warranted to confirm these findings and to explore the long-term benefits of these intensive nursing interventions in delirium management.
Medical science monitor : international medical journal of experimental and clinical researchMichal Kalina, Ondřej Jíra, Vladimír Černý
BACKGROUND Twenty-four-hour fluid balance is routinely used as a surrogate marker of net fluid change in critically ill patients and frequently influences bedside clinical decision-making, including assessment of volume status and fluid management strategies. However, despite its widespread use in intensive care practice, the reliability and accuracy of this routinely recorded parameter as a measure of short-term fluid change remain uncertain. MATERIAL AND METHODS We conducted a prospective multicenter observational study comparing cumulative 24-hour fluid balance with 24-hour body weight change measured over identical time intervals in adult patients admitted to the intensive care unit (ICU). Paired measurements were collected and analyzed to evaluate the agreement between these 2 commonly used approaches for estimating short-term fluid changes. Agreement was assessed using Bland-Altman analysis, including regression-based evaluation of proportional bias. Clinically acceptable agreement was predefined as a difference within ± 1 kg between methods. RESULTS A total of 360 paired observations were analyzed. The mean bias between methods was small (0.082 kg), indicating minimal systematic difference at the population level. However, agreement at the individual level was poor, with wide 95% limits of agreement (-2.1 to +2.264 kg), exceeding the predefined threshold for clinical acceptability. Clinically significant disagreement (> 1 kg) occurred in 30.2% of observations. Proportional bias was present, with increasing discrepancy between methods across the range of measured values, suggesting that disagreement was not consistent across different levels of fluid change. CONCLUSIONS Routinely charted 24-hour fluid balance demonstrates clinically unacceptable agreement with body weight change and should not be considered an interchangeable measure of short-term fluid change in critically ill patients. An integrated approach combining fluid balance assessment, serial body weight measurements, and comprehensive clinical evaluation is recommended to improve assessment of fluid status and guide individualized patient management.
Neurosurgical reviewElena Le Cam, Romain Salette, Lamine Abdennour, Victor Jullien, Vincent Doat Sarfati, Bertrand Mathon, Anne Laure Boch, Eimad Shotar, Frederic Clarençon, Vince…
Intracranial pressure (ICP) monitoring is a cornerstone of the management of patients with acute brain injury. External ventricular drains (EVDs) and intraparenchymal pressure sensors are the two most widely used invasive monitoring modalities. Although both techniques are routinely employed in neurocritical care, discrepancies between simultaneously recorded ICP values may occur because of technical limitations, sensor drift, or physiological intracranial pressuregradients. In this study, we evaluated dual ICP monitoring using EVD and intraparenchymal pressure sensor. The primary objective was to assess the frequency of signal mismatches. The secondary objective was to identify associations with patient diagnosis and device type. This was a single-center, retrospective observational study, from July 2013 to January 2015 and from December 2017 to April 2019. We included ICU patients with traumatic brain injury (TBI) or aneurysmal subarachnoid hemorrhage (aSAH). All patients had dual ICP monitoring with an intraparenchymal pressure sensor and an EVD. Paired ICP measurements were collected every three hours during a 15-day observation period. Three categories of discordance were analyzed: E1: absolute difference > 6 mmHg between EVD and intraparenchymal measurements E2 : EVD-positive / intraparenchymal-negative threshold discordance (EVD > 20 mmHg and intraparenchymal ICP < 20 mmHg) E3: intraparenchymal-positive / EVD-negative threshold discordance (intraparenchymal ICP > 20 mmHg and EVD < 20 mmHg). A total of 313 patients (169 traumatic brain injury and 144 aneurysmalsubarachnoid hemorrhage) were included, providing 22,294 valid paired ICP measurements. Overall, 84% (n = 267) of patients experienced at least one E1 event, whereas 15.7% (n = 49) experienced at least one E2 event and 28.1% (n = 88) at least one E3 event. Agreement between ventricular and intraparenchymal measurements remained acceptable across pathologies and device types. However, discordances occurred more frequently during episodes of intracranial hypertension. Discordance between ventricular and intraparenchymal ICP measurements was not uncommon in this cohort of neurocritical care patients. These findings underscore the complexity of ICP interpretation and highlight the limitations inherent to all invasive monitoring techniques. Although dual monitoring may help identify discordant measurements in selected situations, the clinical significance of these discrepancies and their impact on patient management and outcomes remain to be established.
BMJ openRaphael Theilen, Robert Huhle, Martin Scharffenberg, Franziska Fischer, Tim Kramer, Thea Koch, Lorenzo Ball, Lluis Blanch, Leonardo Sarlabous, Fernando Suárez-…
INTRODUCTION: Mechanical ventilation (MV) is lifesaving in the intensive care unit (ICU) but can cause complications if not individualised according to the patient's needs. Artificial intelligence (AI)-driven decision support systems (AI-DSS) may theoretically optimise MV settings. This international observational, prospective, multicentre study aims to validate the IntelliLung AI-DSS in real clinical environments. METHODS AND ANALYSIS: In this study, patients aged ≥18 years requiring invasive MV for >24 hours are included. The primary objective is to evaluate the agreement between IntelliLung AI-DSS MV recommendations and the ventilator settings implemented by healthcare providers. The IntelliLung AI-DSS continuously analyses patient-specific data, including respiratory mechanics and gas exchange, to recommend optimal MV parameters. The primary endpoints are the relative time of matching ventilator settings for each (1) positive end-expiratory pressure, (2) fraction of inspired oxygen, (3) respiratory rate and (4) tidal volume during volume-controlled ventilation or inspiratory pressure (Pinsp) during pressure-controlled ventilation. Secondary endpoints include assessments of ventilator-free days and clinical decision-making practices. Patient-centred outcomes, such as quality of life and psychological stress, are also evaluated. Data collection spans ICU stay and follow-up at 30 and 180 days after enrolment. This trial is the first to validate the IntelliLung AI-DSS in a prospective, real-world clinical setting by comparing recommendations given by the IntelliLung AI-DSS to local standards of care. The results of the trial will serve as a foundation for future interventional studies to assess the IntelliLung AI-DSS impact on patient outcomes and ICU workflows. The study addresses a critical gap in the application of AI to intensive care, advancing personalised and evidence-based MV management. ETHICS AND DISSEMINATION: The TUD Medical Faculty Ethical Committee for clinical research approved the study on 4 November 2024 (File number Mono-EK-27907202). Additionally, the institutional review board at Sabadell, Madrid and Warsaw approved the study. IntelliLung is designed in accordance with the principles of the Declaration of Helsinki. The final main results will be published in a highly ranked, peer-reviewed scientific journal taking into account the recommendations of the International Committee of Medical Journal Editors. TRIAL REGISTRATION NUMBER: NCT06595602.
BMJ openShannon Tang, Janice Y Kung, Sarah Tymchuk, Kallirroi Laiya Carayannopoulos, M Elizabeth Wilcox
INTRODUCTION: Survivors of intensive care unit (ICU) admission and their families frequently experience persistent physical, cognitive and psychological impairments following critical illness, collectively described as post-intensive care syndrome (PICS) and post-intensive care syndrome-family (PICS-F). These sequelae often emerge during the recovery period after hospital discharge and may affect long-term functioning and quality of life. Social connectivity-the extent to which individuals maintain meaningful social relationships and supportive interactions-has been associated with improved health outcomes in several populations. This scoping review aims to map the existing literature describing social connectivity among ICU survivors and their families and examine how it has been studied in relation to recovery outcomes. METHODS AND ANALYSIS: This scoping review will be conducted using the Joanna Briggs Institute methodology for scoping reviews and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. MEDLINE, EMBASE, CINAHL and PsycINFO will be searched from database inception to December 2025 without language restrictions. Studies examining social connectivity in relation to PICS or PICS-F among adult ICU survivors or their family members will be included. Data will be extracted independently using a standardised charting form and summarised descriptively. ETHICS AND DISSEMINATION: Ethical approval is not required because this study synthesises previously published literature. Findings will be disseminated through publication in a peer-reviewed journal and may inform future research and patient- and family-centred strategies to support recovery after critical illness.
Intensive & critical care nursingP Jane Greaves, Goran Erfani, Dominic Simpson, Barry Hill, Tony Conner, Marika Nemeckova, Amy McCerery, Floraidh Rolf, Daniel Monk, Alison Steven
AIM: This rapid review was conducted for the NHS England Safer Staffing Programme (2024) England (2024) [1] to evaluate the evidence base for adult critical care nurse staffing. The review addressed four objectives: 1) identifying current staffing decision-making processes; 2) evaluating the impact of staffing models on patient outcomes and service efficiency; 3) assessing effects on burnout and staff retention; 4) identifying effective staffing responses during the COVID-19 pandemic. METHODS: A rapid systematic review following PRISMA guidelines was conducted across MEDLINE, CINAHL Plus, PsycINFO, and Scopus (2012-2024). Studies examining quantitative, qualitative, and mixed-methods research on registered nurse staffing in adult intensive care were included. FINDINGS: Eighty-six studies met the inclusion criteria. Current staffing guidelines predominantly rely on expert consensus (Level 7 evidence) with day-to-day adaptation by senior nurse managers. Emerging empirical data (Level 4-5) suggest an association between nurse-to-patient ratios of 1:1 or higher and reduced mortality and nosocomial infections, though heterogeneity across studies precludes defining an optimal ratio. Workload intensity may be a more sensitive predictor of outcomes than static ratios. High nursing workloads are associated with increased burnout and turnover. Pandemic responses demonstrated that while "upskilling" non-ICU nurses supported surge capacity, it increased the psychological burden on experienced ICU staff. CONCLUSIONS: While current guidelines rely heavily on expert opinion, there is some evidence from the literature to suggest that moving toward objective, workload-based frameworks might address limitations in current consensus-based models. However, the existing evidence base is largely observational, necessitating further high-quality research to confirm these associations. IMPLICATIONS FOR CLINICAL PRACTICE: Healthcare organisations should consider integrating objective workload measurement tools to supplement the professional judgement of the Nurse in Charge. Such an approach may provide a more defensible basis for workforce planning and help mitigate the impact of rising patient acuity on staff retention.
BMC geriatricsAdrian Rosada, Drin Ferizaj, Nils Lahmann, Frank Samuel Schaefer, Ursula Müller-Werdan
BACKGROUND: Physicians treating older patients are frequently unaware of their patients' personal attitudes towards life-sustaining measures like ventilation, resuscitation, feeding tubes, or ICU admission. In routine clinical practice, there is often little time for reflection prior to deciding in favor or against life sustaining measures in critical medical conditions. Although decisions for or against these measures should ideally be made jointly by the patient and the treating physician, factors like age, disease burden, social inclusion, and affective state may play an important role in the patient's motivation. METHODS: Data from 161 inpatients (mean age 82.0 years) on a geriatric ward were collected and analyzed. Patients were interviewed about their attitudes towards life-sustaining measures like ventilation, resuscitation, tube feeding, ICU admission, and dialysis. Four composite indices were formed by combining sign-aligned component variables: medical burden (age and Charlson Comorbidity Index), functional and cognitive impairment (Barthel Index, iADL, and MoCA), affective distress (Geriatric Depression Scale and Hamilton Depression Scale suicidality item), and social support (living situation, having children, and having friends). These indices with other covariates were then analyzed using a Bayesian Rasch item response model with latent regression. RESULTS: Overall, 14.3% refused all invasive life sustaining measures, whereas 33.8% wished to receive all of the measures listed above. Artificial nutrition was the most refused measure (refused by 53.4%), whereas ICU admission was the most commonly accepted measure (74.4%). Social support had no meaningful association with the decision to accept or refuse life-sustaining measures. Relevant predictors were primarily lower levels of affective distress, and secondarily better functional and cognitive performance and lower medical burden. CONCLUSIONS: Even among older patients, only a minority completely reject life-sustaining measures, even though their life expectancy is often significantly reduced. Patient's attitude towards life-sustaining measures appears to be related more strongly to affective state, functional performance, and medical burden than living situation or social inclusion. As the patient's emotional and functional state can certainly be influenced by medical treatment, practitioners should bear this in mind and, where appropriate, reassess their patients' attitude towards LSM once the aforementioned conditions have improved. CLINICAL TRIAL NUMBER: Registered with the clinical trial registry Deutsches Register Klinischer Studien.