Cognitive Impairment and Psychological Distress at Discharge from Intensive Care Unit

Perceptions of adult intensive care unit patients regarding nursing presence and their intensive care experiences: A descriptive-correlational study

AIMS AND OBJECTIVES

This study aims to determine the relationship between perceptions of nursing presence and intensive care experiences in adult intensive care unit patients'.

BACKGROUND

Intensive care units (ICUs) are settings where patients have many negative emotions and experiences, which affect both treatment and post-discharge outcomes. The holistic presence of nurses may help patients turn their negative emotions and experiences into positive ones.

DESIGN

A descriptive-correlational design was used and reported according to the STROBE checklist.

METHODS

The sample consisted of 182 participants. Data were collected using a personal information form, the Glasgow Coma Scale (GCS), the Intensive Care Experience Scale (ICES), and the Presence of Nursing Scale (PONS).

RESULTS

A strong positive correlation existed between total ICES and PONS scores (r = 0.889, p < 0.001). There was a strong positive correlation between PONS total score and ICES subscales (awareness of surroundings (r = 0.751, p < 0.001), frightening experiences (r = 0.770, p < 0.001), recall of experience (r = 0.774, p < 0.001), and satisfaction with care (r = 0.746, p < 0.001)). Males (β = -0.139, p < 0.05), and patients who were university and higher education graduate (β = 0.137, p < 0.05) had higher positive ICU experiences. It was also found length of ICU stay was correlated with ICU experiences and nursing presence.

CONCLUSIONS

The more positively the patients perceive nurses, the better ICU experiences they have. Gender and education level were found determinants of adult ICU patients' experiences. ICU length of stay predicted what kind of experience patients have and how much they feel the presence of nurses.

RELEVANCE TO CLINICAL PRACTICE

Nurses should make their presence felt completely and holistically by using their communication skills for patients have more positive intensive care experiences. Nurses should consider variables which affects patients' ICU experiences and nursing presence.

Association of level of adherence to Mediterranean diet with cognitive and dementia status in subjects with chronic diseases: a cross-sectional study

BACKGROUND

The Mediterranean diet has been linked to brain neuroprotection. Evidence from meta-analyses showed reduced risk of dementia with greater intake of vegetables and fruits, fish, and the Mediterranean diet. The current study raises important questions about the association between low risk dementia and Mediterranean diet.

OBJECTIVE

The objective was to evaluate the association between levels of adherence to the Mediterranean diet and dementia and cognitive status in subjects 50 years of age and older.

METHOD

The Mediterranean Diet Adherence Screener (MEDAS), the modified 30-item 'Diagnostic and Statistical Manual of Mental Disorders Third Edition (DSM-III) risk of dementia, and the Standard Mini-Mental Status Examination (SMMSE) cognitive status scores were used to assess the levels of adherence to the Mediterranean diet'.

RESULTS

A total of 150 subjects were enrolled in the study. Forty-one (27.3%) had 'suspected or confirmed dementia, while 48 individuals (32%) were categorized as having moderate to severe cognitive decline. Subjects who reported moderate to high adherence to the Mediterranean diet (55, 36.7%) had significantly lower dementia scores (7.0 3.8 versus 17.6 5.1) and higher cognitive (25.4 3.8 versus 8.6 7.2) scores compared to those (38, 25.3%) who reported low adherence to the Mediterranean diet.

CONCLUSION

Subjects who were highly or moderately adherent to the Mediterranean diet had significantly lower dementia scores and better cognitive status than those with low adherence.

Cognitive impairment in critically ill patients and former critically ill patients: A concept analysis

OBJECTIVES

This concept analysis aimed to clarify the meaning of the concept of cognitive impairment in critically ill patients throughout the trajectory of their rehabilitation during and after an intensive care unit admission.

REVIEW METHODS USED

This study used concept analysis based on Rodgers' evolutionary method.

DATA SOURCES

A systematic search was conducted in Cumulative Index to Nursing and Allied Health Literature, Public MEDLINE, and American Psychological Associations PsycINFO. The web was searched for grey literature.

REVIEW METHODS

Overall search terms used were "patients with cognitive impairments" AND "intensive care unit". Literature published between 2008 and 2022 was included and screened by title and abstract using systematic review software. The descriptive analysis focussed on surrogate terms/related concepts, attributes, and contextual basis.

RESULTS

Thirty studies were included, representing variability in study design and country of origin. The analysis uncovered descriptions of the general terminology and the temporal trajectory of the concept, spanning from the acute phase to a long-term perspective. Attributes of the concept were described as delirium and domains of cognition. Antecedents were juxtaposed to risk factors, which were multifactorial. Consequences of cognitive impairment related to patients' quality of life, such as a decline in their ability to function independently, return to work, and manage everyday life. Also, cognitive impairment was identified as a significant public health problem.

CONCLUSION

Cognitive impairment is a complex concept with many surrogate and related terms. Furthermore, the concept is inextricably intertwined with the concepts of delirium and post-intensive care syndrome. Cognitive impairment may manifest as symptoms that can be challenging to identify and assess due to limitations in current screening tools and the absence of a consensus on timing. In relation to assessment and preventive strategies, the findings underline the need to distinguish between acute and long-term cognitive impairment.

REGISTRATION

There is no study registration number.

Nurses' experiences of managing cognitive problems in intensive care unit patients: A qualitative study

OBJECTIVES

Nurses hold a key position in identifying symptoms and initiating preventive strategies for cognitive impairment in delirious and non-delirious intensive care unit patients. However, it remains unclear whether nurses consider cognitive impairment as a distinct concern from delirium. By understanding nurses' perspectives, we may identify barriers and facilitators in caring for patients with cognitive challenges in the intensive care unit. The objective of this study was to explore nurses' experiences of cognitive problems in patients admitted to an intensive care unit.

RESEARCH METHODOLOGY

A phenomenological-hermeneutic study of interviews with ten nurses from intensive care units. Data were collected in March-April 2022 and analysed using a Ricœur-inspired method of interpretation.

FINDINGS

Three themes related to nurses' experiences of cognitive problems emerged through analysis; 1) Cognitive problems and delirium are seen as two sides of the same coin, 2) Searching for the person behind the patient, and 3) Maintaining a sense of normality in a confusing environment.

CONCLUSIONS

The interconnected concept of cognitive impairment and delirium syndrome meant that nurses assessed and managed cognitive problems in intensive care unit patients by focusing on preventing delirium. Apart from delirium screening, nurses relied on relatives' knowledge to assess patients' cognition. Most significantly, our study revealed a previously unexplored approach by nurses to manage patients' cognition, which involved "shielding" patients from the noisy and disruptive intensive care unit environment.

IMPLICATIONS FOR CLINICAL PRACTICE

Effective communication methods, coupled with family involvement may aid nurses in identifying patients' cognitive problems. In the acute phase of critical illness, distinguishing between delirium and cognitive problems may not be clinically relevant, as delirium protocols may protect patients' cognition. Further investigating the concept of shielding may reveal previously unexplored nursing approaches to manage cognitive problems.

Forecasting Caseload of Critically Ill Patients Who Are Alert and Without Delirium for at Least Two Consecutive Days for the Assessment of Their Psychological Distress

INTRODUCTION

One-quarter of alert, non-delirious patients in critical care units report significant psychological distress. Treatment of this distress depends upon identifying these high-risk patients. Our aim was to characterize how many critical care patients remain alert and without delirium for at least two consecutive days and could thus predictably undergo evaluation for distress.

METHODS

This retrospective cohort study used data from a large teaching hospital in the United States of America, from October 2014 to March 2022. Patients were included if they were admitted to one of three intensive care units, and for >48 hours all delirium and sedation screenings were negative (Riker sedation-agitation scale four, calm and cooperative, and no delirium based on all Confusion Assessment Method for the Intensive Care Unit scores negative and all Delirium Observation Screening Scale less than three). Means and standard deviations of means for counts and percentages are reported among the most recent six quarters. Means and standard deviations of means for lengths of stay were calculated among all N=30 quarters. The Clopper-Pearson method was used to calculate the lower 99% confidence limit for the percentages of patients who would have had at most one assessment of dignity-related distress before intensive care unit discharge or change in mental status.

RESULTS

An average of 3.6 (standard deviation 0.2) new patients met the criteria daily. The percentages of all critical care patients (20%, standard deviation 2%) and hours (18%, standard deviation 2%) meeting criteria decreased slightly over the 7.5 years. Patients spent a mean of 3.8 (standard deviation 0.1) days awake in critical care before their condition or site changed. In the context of assessing distress and potentially treating it before the date of change of condition (e.g., transfer), 66% (6818/10314) of patients would have zero or one assessment, lower 99% confidence limit of 65%.

CONCLUSIONS

Approximately one-fifth of critically ill patients are alert and without delirium and thus could be evaluated for distress during their intensive care unit stay, mostly during a single visit. These estimates can be used to guide workforce planning.

Patient Safety: Cognitive Assessment at Intensive Care Unit Discharge

Topic

Assessing functional cognition is a critical need for intensive care unit survivors transitioning to another level of care.

Clinical Relevance

Up to 62% of patients discharged from an intensive care unit have significant cognitive impairment that is not associated with severity of illness, number of comorbidities, or length of hospital stay. For more than 20 years, researchers have published an array of potentially effective interventions, including case management, patient and informal caregiver education, and home health care services.

Purpose

To describe the impact of and potential interventions for cognitive decline at intensive care unit discharge and discharge readiness on 30-day readmission rates.

Content Covered

Assessing the patient’s functional cognition assessment and advocating for appropriate resources are needed to improve patient and clinical outcomes.

Pancreatitis associated anxiety, depression, and stress: Hypothesis, definition, and intervention

Necrotizing pancreatitis is characterized by a prolonged disease course requiring frequent hospitalization and intervention. Necrotizing pancreatitis patients have high rates of intensive care unit admission and organ failure. Critical illness is an identified risk factor for the development of anxiety, depression, and posttraumatic stress disorder. Limited literature examines quality of life in necrotizing pancreatitis patients, and studies examining psychiatric sequalae of necrotizing pancreatitis including depression, anxiety, and posttraumatic stress disorder are virtually nonexistent. Here, we review critical literature examining risk factors for poor mental health outcomes during and after necrotizing pancreatitis, identify several screening instruments to quantify mental health outcomes, and propose an intervention to improve mental health outcomes in patients with necrotizing pancreatitis. We conclude that establishing the incidence of mental health disorders and implementing strategies to improve mental health outcomes are critical to holistic care of necrotizing pancreatitis patients.

Lessons from a review of physiotherapy and psychological rehabilitation received during ICU stay and beyond to inform the development of an ICU follow clinic

BACKGROUND

Critical illness can have a long-term impact. A service evaluation was conducted in a hospital in the south west of Britain with an adult inter-connected general, surgical and neurological intensive care unit (ICU). The aim of the service evaluation was to generate knowledge on experiences of psychological and physical rehabilitation in intensive care, on other hospital wards and at home to inform the development of an Intensive Care follow up clinic.

METHOD

Data was collected from two sources. A week of ICU discharges was randomly selected, and a sample of 30 patients generated. All were sent information sheets and consent forms and offered telephone appointments. 12 participants took part in telephone interviews. The second source of participants was the ICU Expert by Experience group. Informed consent was gained with eight participants taking part. The data was analysed using thematic analysis, employing initial open coding to build a framework of emergent themes. A research group was formed to facilitate cross coding of extracts.

RESULTS

The analysis identified three overarching themes: sense making difficulties; rehabilitation context; and sense of self. The theme of sense making difficulties had sub-themes of memory gaps, delirium, lack of information and anxiety. The theme of rehabilitation context had sub-themes of ICU environment, transitions, isolation and abandonment and valued support.

CONCLUSION

the process of sense making can be difficult, is filtered through contextual factors, and may influence sense of self. The results have been used to inform the development of an ICU follow up clinic.

Clinical Outcomes in Routine Evaluation Measures for Patients Discharged from Acute Psychiatric Care: Four-Arm Peer and Text Messaging Support Controlled Observational Study

Background: Peer support workers (PSW) and text messaging services (TxM) are supportive health services that are frequently examined in the field of mental health. Both interventions have positive outcomes, with TxM demonstrating clinical and economic effectiveness and PSW showing its utility within the recovery-oriented model. Objective: To evaluate the effectiveness of PSW and TxM in reducing psychological distress of recently discharged patients receiving psychiatric care. Methods: This is a prospective, rater-blinded, pilot-controlled observational study consisting of 181 patients discharged from acute psychiatric care. Patients were randomized into one of four conditions: daily supportive text messages only, peer support only, peer support plus daily text messages, or treatment as usual. Clinical Outcomes in Routine Evaluation—Outcome Measure (CORE-OM), a standardized measure of mental distress, was administered at four time points: baseline, six weeks, three months, and six months. MANCOVA was used to assess the impact of the interventions on participants’ scores on four CORE-OM subscales across the three follow-up time points. Recovery, clinical change, and reliable change in CORE-OM all-item analysis were examined across the four groups, and the prevalence of risk symptoms was measured. Results: A total of 63 patients completed assessments at each time point. The interaction between PSW and TxM was predictive of differences in scores on the CORE-OM functioning subscale with a medium effect size (F1,63 = 4.19; p = 0.045; ηp2 = 0.07). The PSW + TxM group consistently achieved higher rates of recovery and clinical and reliable improvement compared to the other study groups. Additionally, the text message group and the PSW + TxM group significantly reduced the prevalence of risk of self/other harm symptoms after six months of intervention, with 27.59% (χ2(1) = 4.42, p = 0.04) and 50% (χ2(1) = 9.03, p < 0.01) prevalence reduction, respectively. Conclusions: The combination of peer support and supportive text messaging is an impactful intervention with positive clinical outcomes for acute care patients. Adding the two interventions into routine psychiatric care for patients after discharge is highly recommended.

Recall of Intensive Care Unit Stay in Critical Illness Survivors in Southeast Iran

BACKGROUND

In survivors of critical illness, recall of an intensive care unit stay plays an important role in the development of post-intensive care unit syndrome, which includes psychological impairment after intensive care unit discharge.

OBJECTIVE

To investigate memories of the intensive care unit among survivors in southeast Iran.

METHODS

In this descriptive study, the intensive care unit memory tool was used to assess patients' memories of intensive care units.

RESULTS

All participants (N = 100) had 1 or more factual memories (89%), memories of feelings (66%), or delusional memories (34%) from the intensive care unit. Patients who received mechanical ventilation were 4 times as likely to have delusional memories as those who did not receive mechanical ventilation. Unmarried patients were 4.8 times as likely as married patients to have memories of feelings from the intensive care unit.

CONCLUSIONS

Steps should be taken to minimize distressing memories of an intensive care unit admission. Follow-up programs should take into account the psychological problems faced by intensive care unit survivors.

Post-intensive care syndrome: A concept analysis

OBJECTIVE

Post-intensive care syndrome is a term used to describe new or worsening multidimensional impairments in physical, psychological cognitive and social status arising from critical illness and persisting beyond hospital discharge. It is associated with high morbidity among patients discharged from intensive care units. However, due to its complexities, which encompass physical, psychological, cognitive and social impairments, the exact nature of this condition has not been fully conceptualized. The aim of this analysis therefore was to define the concept of post-intensive care syndrome. This conceptual clarity provides a general definition that is essential for practitioners and researchers to gain a comprehensive understanding of the syndrome and provide for accurate measurement of its incidence and prevalence.

DESIGN

The Walker and Avant approach to concept analysis guided this investigation.

DATA SOURCE

An electronic search of the literature using PubMed, CINHAL, PsycArticles, Academic search complete, Science Direct, MEDLINE and Health Source databases informed the analysis. The search included both quantitative and qualitative studies related to post-intensive care syndrome published in English between 2010 and 2020.

RESULTS

Of the 3948 articles identified, 24 ultimately met the inclusion criteria. Analysis identified the defining attributes of post-intensive care syndrome as: (1) new or worsening multidimensional impairments; (2) physical dysfunction; (3) psychological disorder; (4) cognitive impairment; (5) failed social reconstruction; and (6) persistent impaired multidimensional symptoms extending beyond intensive care and hospital discharge. Antecedents were divided into two categories: pre-existing and those related to the intensive care admission. Consequences were identified as both positive (for example the establishment of coping processes) and adverse (for example decreased quality of life and caregiver burden).

CONCLUSION

Post-intensive care syndrome affects more than half of patients discharged from intensive care units. This operational definition and conceptual understanding of this syndrome will help improve understanding and inform the design of preventative strategies to improve long-term consequences of the syndrome. Future research and standardized instrument development will serve to better understand the scope and characteristics of this syndrome and inform the development of possible preventative interventions.

Instruments to measure outcomes of post-intensive care syndrome in outpatient care settings - Results of an expert consensus and feasibility field test

Background

There is no consensus on the instruments for diagnosis of post-intensive care syndrome (PICS). We present a proposal for a set of outcome measurement instruments of PICS in outpatient care.

Methods

We conducted a three-round, semi-structured consensus-seeking process with medical experts, followed each by exploratory feasibility investigations with intensive care unit survivors (n₁ = 5; n₂ = 5; n₃ = 7). Fourteen participants from nine stakeholder groups participated in the first and second consensus meeting. In the third consensus meeting, a core group of six clinical researchers refined the final outcome measurement instrument set proposal.

Results

We suggest an outcome measurement instrument set used in a two-step process. First step: Screening with brief tests covering PICS domains of (1) mental health (Patient Health Questionnaire-4 (PHQ-4)), (2) cognition (MiniCog, Animal Naming), (3) physical function (Timed Up-and-Go (TUG), handgrip strength), and (4) health-related quality of life (HRQoL) (EQ-5D-5L). Single items measure subjective health before and after the intensive care unit stay. If patients report new or worsened health problems after intensive care unit discharge and show relevant impairment in at least one of the screening tests, a second extended assessment follows: (1) Mental health (Patient Health Questionnaire-8 (PHQ-8), Generalized Anxiety Disorder Scale-7 (GAD-7), Impact of Event Scale - revised (IES-R)); (2) cognition (Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Trail Making Test (TMT) A and B); (3) physical function (2-Minute Walk Test (2-MWT), handgrip strength, Short Physical Performance Battery (SPPB)); and (4) HRQoL (EQ-5D-5L, 12-Item WHO Disability Assessment Schedule (WHODAS 2.0)).

Conclusions

We propose an outcome measurement instrument set used in a two-step measurement of PICS, combining performance-based and patient-reported outcome measures. First-step screening is brief, free-of-charge, and easily applicable by health care professionals across different sectors. If indicated, specialized healthcare providers can perform the extended, second-step assessment. Usage of the first-step screening of our suggested outcome measurement instrument set in outpatient clinics with subsequent transfer to specialists is recommended for all intensive care unit survivors. This may increase awareness and reduce the burden of PICS.

Trial registration

This study was registered at ClinicalTrials.gov (Identifier: NCT04175236; first posted 22 November 2019).

The intensive care unit: How to make this unfriendly environment geriatric-friendly

Patients 80 years old or older are increasingly being admitted to intensive care units, particularly in western countries, where life expectancy is constantly increasing. The benefits of intensively treating critically ill elderly patients are uncertain. The high mortality rate in the presence of underlying chronic diseases is a factor. More generally, frailty, defined as an impaired resilience following a health stressor event, must be taken into account. No consensus exists on the risk-benefit ratio to admit octogenarians to the ICU. Treatment decisions should account for life expectancy but also tailored to the needs and wishes of patients and next-of-kins. The cohort of elderly patients is known to be the most vulnerable to functional decline and cognitive impairment, including neuropsychological complications, such as delirium.. Interventions directed at reducing the incidence of delirium may mitigate brain injury associated with critical illness, potentially being the single most effective intervention in this population. A multimodal approach to analgesia should be considered to avoid untreated pain and its consequences. Sleep protocols can effectively reduce the risk of delirium. Notably, the deployment of "sleep bundles" (regular sleep-wake rhythms, reduced night-time light, noise control strategies), may be helpful. As well, adequate nutritional support, spontaneous awakening trials, early mobilization, and physical therapy are crucial to prevent physical deconditioning. The psychological consequences of critical illness for both patients and caregivers are also being increasingly recognized. Attention to the needs of families is essential, due to its positive effects on patients and as a quality improvement goal by itself. Death and dying in the ICU is a more frequent outcome in the elderly population. A real culture for the management of distress and grieving is a required skill for the ICU staff. Privacy and adequate palliative care should be contemplated for an ethical and comfortable end of life.

Review: Post-Intensive Care Syndrome: Unique Challenges in the Neurointensive Care Unit

Within the last couple of decades, advances in critical care medicine have led to increased survival of critically ill patients, as well as the discovery of notable, long-term health challenges in survivors and their loved ones. The terms post-intensive care syndrome (PICS) and PICS-family (PICS-F) have been used in non-neurocritical care populations to characterize the cognitive, psychiatric, and physical sequelae associated with critical care hospitalization in survivors and their informal caregivers (e.g., family and friends who provide unpaid care). In this review, we first summarize the literature on the cognitive, psychiatric, and physical correlates of PICS and PICS-F in non-neurocritical patient populations and draw attention to their long-term negative health consequences. Next, keeping in mind the distinction between disease-related neurocognitive changes and those that are associated directly with the experience of a critical illness, we review the neuropsychological sequelae among patients with common neurocritical illnesses. We acknowledge the clinical factors contributing to the difficulty in studying PICS in the neurocritical care patient population, provide recommendations for future lines of research, and encourage collaboration among critical care physicians in all specialties to facilitate continuity of care and to help elucidate mechanism(s) of PICS and PICS-F in all critical illness survivors. Finally, we discuss the importance of early detection of PICS and PICS-F as an opportunity for multidisciplinary interventions to prevent and treat new neuropsychological deficits in the neurocritical care population.

Challenges in conducting long-term outcomes studies in critical care

PURPOSE OF REVIEW

Evaluating longer term mortality, morbidity, and quality of life in survivors of critical illness is a research priority. This review details the challenges of long-term follow-up studies of critically ill patients and highlights recently proposed methodological solutions.

RECENT FINDINGS

Barriers to long-term follow-up studies of critical care survivors include high rates of study attrition because of death or loss to follow-up, data missingness from experienced morbidity, and lack of standardized outcome as well as reporting of key covariates. A number of recent methods have been proposed to reduce study patients attrition, including minimum data set selection and visits to transitional care or home settings, yet these have significant downsides as well. Conducting long-term follow-up even in the absence of such models carries a high expense, as personnel are very costly, and patients/families require reimbursement for their time and inconvenience.

SUMMARY

There is a reason why many research groups do not conduct long-term outcomes in critical care: it is very difficult. Challenges of long-term follow-up require careful consideration by study investigators to ensure our collective success in data integration and a better understanding of underlying mechanisms of mortality and morbidity seen in critical care survivorship.

Psychocognitive sequelae of critical illness and correlation with 3 months follow up

PURPOSE

Over a third of critical illness survivors manifest significant psychocognitive impairments following discharge from the intensive care unit (ICU). It is not known which patient populations are at highest risk or if assessment at ICU discharge can guide outpatient treatment prioritization.

MATERIALS AND METHODS

Prospective single center study in an academic medical center encompassing six types of ICUs assessed prevalence of psychocognitive morbidity based on ICU type and associations between initial and 3 month follow-up evaluation. Adult patients with >48 h ICU stays completed the Hospital Anxiety and Depression Scale (HADS), Impact of Events Scale-Revised (IES-R), and Montreal Cognitive Assessment-Blind (MoCA-blind).

RESULTS

Of 299 patients who underwent initial assessment, 174 (58%) completed follow-up. Length of stay, MoCA-Blind, HADS-A/D and IES-R scores were similar across ICUs. Most commonly observed impairment in-hospital was cognitive (58%) followed by anxiety (45%), acute stress (39%) and depression (37%). There were significant correlations between in-hospital and follow-up psychocognitive outcomes.

CONCLUSIONS

There was no significant difference in impairment by ICU type. Significant correlation between the initial assessment and follow-up scores suggests that early screening of high risk patients may identify those at greatest risk of sustained morbidity and facilitate timely intervention.

Critically ill patients' experiences of nursing care in the intensive care unit

BACKGROUND

Understanding critically ill patients' experiences of nursing care is an important aspect that can improve quality of care in the intensive care unit.

AIM

To elicit critically ill patients' experiences of nursing care in the adult intensive care units.

DESIGN

A qualitative descriptive design was utilized.

METHODS

Sixteen patients who had a predicted mortality risk of above 50% within the first 24 h of admission to the intensive care unit and had been discharged to the ward were purposively selected. The study was conducted at three academic affiliated, tertiary/quaternary specialist hospitals in South Africa. Individual semi-structured interviews were conducted with the selected participants until a point of data saturation was reached. Data were analysed using a conventional content analysis technique (Hsieh and Shannon, 2005). Lincoln and Guba's criteria for ensuring the trustworthiness of qualitative research were applied.

FINDINGS

Four major themes emerged: 'being in someone's shoes', 'communication', 'presence' and 'religion and spirituality'.

CONCLUSIONS

Even though some participants' responses reflected 'good' nursing care, the majority of the participants had negative experiences in relation to the nursing care they received while admitted in the selected intensive care units.

RELEVANCE TO CLINICAL PRACTICE

This study demonstrates critically ill patients' voices and preferences of intensive nursing care and describes some issues that require not only nurses' but also managerial improvements and interventions in order to ensure quality care and, eventually, patients' satisfaction with intensive nursing care.

Medical hypothesis: Light at night is a factor worth considering in critical care units

Exposure to light at night is not an innocuous consequence of modernization. There are compelling data linking long-term exposure to occupational and environmental light at night with serious health conditions, including heart disease, obesity, diabetes, and cancer. However, far less is known about the physiological and behavioral effects of acute exposure to light at night. Among healthy volunteers, acute night-time light exposure increases systolic blood pressure and inflammatory markers in the blood, and impairs glucose regulation. Whether critically ill patients in a hospital setting experience the same physiological shifts in response to evening light exposure is not known. This paper reviews the available data on light at night effects on health and wellbeing, and argues that the data are sufficiently compelling to warrant studies of how lighting in intensive care units may be influencing patient recovery.