What's in this issue?

This issue covers the importance of sleep in the intensive care unit (ICU) and the other papers relate in some way to the families of critically ill patients. The papers convey research conducted in various settings and countries and draw upon a range of methodologies and methods to evidence the key findings to address the research questions. When examining these aspects of critical care practice, it is evident how important it is for all of us to remain committed to critical care practice and to experience strong leadership, especially in challenging times. The editorial explores how we can purposefully engage in succession planning to ensure we spot talent and nurture potential to ensure key positions will remain filled by competent, compassionate, critical care nurses. The argument is made that succession planning should not focus solely on senior management positions but also on posts that are pivotal in shaping high quality, effective care that is sustainable throughout dynamic and changing times. The Australian descriptive qualitative study by Butler et al. (2017) addresses an important gap in the literature by exploring nurses' perceptions of working with families of critically ill children in a mixed adult cum paediatric ICU. Nurses' experiences were characterised by role confusion, an exchange of information with family members and the important influence of the contextual environment. The overarching theme emerging from the interviews was a clash between nurses' values and the culture of the unit, compounded by a potential conflict and power struggle between nurses and family members. Limitations of the study include its small sample recruited from a single unit and its failure to include any male participants, but these are compensated for by in-depth meticulously analysed data which reveal important aspects of nurses' work with families of critically ill children. The findings underscore challenges in implementing family-centred care in units catering for both adult and paediatric critically ill patients, and suggest that these require renewed efforts by educators and policy makers in assisting practitioners to achieve cultural change. Hajj et al. (2017) conducted a cross-sectional descriptive survey to assess the satisfaction of families with the care of their loved ones in a critical care unit in a large university medical centre in Beirut. In the process, they assessed the internal reliability and construct validity of the Critical Care Family Satisfaction Survey in a Lebanese population, both of which were acceptable. Families were generally satisfied with the care. ‘Assurance’ was ranked as the highest and ‘comfort’ as the lowest source of satisfaction. Younger and better educated families were significantly less satisfied. Of note, the information needs of Christian families were less satisfied than those of Muslim ones. Furthermore, families of critically ill children were the least satisfied with care, which may be explained by the challenges in providing family-centred care in critical care units highlighted in Butler et al.'s (2017) study. The study is limited by a relatively small sample size from a single health facility but contributes to the body of knowledge on families' perceptions of the critical care provided to their loved ones in various cultures and contexts. As pointed out by the authors, however, various facets of families' satisfaction cannot be captured quantitatively which indicates the need for more qualitative research about the factors that enhance and hinder such satisfaction during a period of uncertainty, anxiety and powerlessness. This is particularly relevant because research has consistently shown that there is a discrepancy between the needs of critically ill patients' relatives and health professionals' perceptions of those needs (Kosco and Warren, 2000; Dowling and Wang, 2005; Myhren et al., 2011). As more patients are surviving critical illness, it is increasingly important to study the long-term consequences of a prolonged stay in an ICU. This led Svenningsen et al. (2017) to conduct an integrative literature review about post-ICU symptoms and follow-up programmes that can address them. Their extensive search, spanning across six health sciences databases, retrieved 41 relevant original studies which were subsequently reviewed using the Garrard's (2007) Matrix Method. The review confirms that several former ICU patients experience a range of difficulties, including a lower quality of life, lengthy interruptions to their education and employment and post-traumatic stress disorder. Their close relatives tend to be affected as well, both psychologically and in terms of the increased burden of supporting their loved ones following discharge. Several nurse-led follow-up interventions have been introduced with mixed results, but the review reports particularly promising effects of return visits to the ICU after discharge on former patients' satisfaction and quest for meaning. The findings should prompt nurses to prepare critically ill patients and their relatives for the possibly prolonged physical, psychological and social effects of their critical care admission, and alert them to the available follow-up services, whereas researchers should continue investigating the effectiveness of such services. The feasibility and efficacy of a nursing intervention involving family members in delirium management following cardiac surgery was the focus of a randomised pilot study by Mailhot et al. (2017). Thirty patient/family caregiver pairs were randomly allocated to receive usual care (consisting of evidence-based pharmacological and non-pharmacological measures but without the systematic involvement of family caregivers) or the intervention (in which, in addition to usual care, a nurse acted as a mentor and provided information on delirium management to the family caregiver who then collaborated with the nurse in various aspects of delirium management). The intervention was deemed feasible and acceptable, based on the high consent rate (77%) and because almost all the participants considered the intervention as extremely appropriate. Patients in the intervention group achieved significantly better psycho-functional recovery scores than those receiving usual care (p = 0.01). However, there was no significant difference in mean delirium severity scores or in the incidence of complications during the follow-up period, which could partly be explained by the comprehensive evidence-based interventions provided to the patients in the control group. The small sample size—not based on formal power calculations—and the imbalance between the groups constitute important limitations. Nonetheless, the strict recruitment and randomisation procedures, the accurate follow-up using validated instruments and the acceptability of the intervention suggest that this pilot study could be the basis of larger trials on the effectiveness of family-based interventions in delirium management during critically illness. A frequently overlooked aspect of critical care is that of caring for patients with chronic critical illness, which typically requires prolonged periods of mechanical ventilation and other life-sustaining technologies, and thus requires extensive, and often repeated, ICU admissions. Leung et al. (2017) conducted in-depth interviews with 16 nurses from five critical care units in an academic hospital in Toronto as part of a qualitative study guided by Thorne's (2008) interpretive descriptive methodology. The data provide compelling insight into nurses' experiences of working with chronically critically ill patients and their relatives, with a focus on the challenge of providing palliative and end-of-life care in settings in which aggressive treatment is the norm. The study highlights the internal tensions between nurses' knowledge of patients' poor prognosis and their desire to protect families from suffering, intensified by constraints to their agency due to limited communication with—and occasionally diverging interests of—families and the multidisciplinary team. Consequently, apart from studying this important facet of critical care in a range of other settings, researchers should explore the perspective of family members and other health professionals. It is also evident that nurses need educational, psychological and institutional support to deal with these challenges and to facilitate their involvement in decisions about transitions from acute to palliative and end-of-life care. The final two papers in this issue focus on the assessment and documentation of the sleep quality and quantity in critical care settings. Ritmala-Castren et al. (2017) investigated nurses' documentation of critically ill patients' sleep, patients' perceptions of their own sleep and the congruence between the two in a 16-bed mixed ICU. The researchers used the Richards-Campbell Sleep Questionnaire (RCSQ), a validated and highly reliable instrument which assesses depth of sleep, falling asleep, number of awakenings, percentage of time awake and overall sleep quality. Sleep quantity and quality was documented for 71% and 27% of the patients, respectively. A closer look at the documentation revealed that some form of documentation about the previous night's sleep was included for 90 of the 114 patients, but this mostly included information about only one of the five elements of the RCSQ. Nurses' documentation correlated with patients' perceptions in 57% of the cases, which is higher than several earlier studies but confirms nurses' tendency to overestimate patients' sleep quantity and quality. The study offers critical care practitioners an opportunity to reflect on their own documentation practices. The effectiveness of measures to aid sleep were well documented, but nurses' documentation of patients' sleep was unsystematic and incomplete, which is of concern, as are the findings confirming that most ICU patients' sleep is light and unsatisfactory. Poor sleep quality and sleep disturbances during critical illness have been associated with morbidity, mortality and longer hospital stays. This underscores the importance of assessing critically ill patients' sleep quality through validated and reliable instruments. Conscious of the importance of reflecting cultural and linguistic nuances in such sleep assessment tools, Krotsetis et al. (2017) translated the original RCSQ to German and tested it in a heterogeneous sample of 51 critically ill patients from three ICUs in a university hospital in Lübeck. A Cronbach's alpha of 0.88 was achieved, indicating very good internal consistency. The participants identified anxiety, disruption by staff for care interventions and a noisy environment as the main reasons for unsatisfactory sleep. This study should serve as a guide for other researchers attempting to adapt a research instrument to the native language of the participants, but also as an eye-opener for practitioners to intensify their efforts at improving critically ill patients' sleep quantity and quality, especially in view of its well-documented effects on patient outcomes. We hope you enjoy reading these papers as much as we have and find insights that can help you reframe your thinking and consolidate your practice for the care of the critically ill patient.

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