Patients' and family members' dyadic experience of post-operative delirium in the intensive care unit: A qualitative study.

What is known about the topic

The experience of post‐operative delirium (POD) in the intensive care unit (ICU) has multiple distressing and lasting negative effects on patients and their family members.

No specific POD prevention or treatment is available, and there is still room for improvement in clinical POD management strategies, which may require the development of better intervention programmes.

Family members are crucial to the overall care provision of patients and play an important role in preventing and reducing POD episodes. Research on the dyadic experiences of patients with POD and their family members in the ICU is limited.

What this paper adds

Throughout the perioperative period, the importance of contemporaneous, accurate and flexible information sharing about POD between families and medical staff is highlighted, including information about family experiences that may affect patients' perceived risk.

Family engagement in POD care has potential advantages, as family members showed subjective initiatives and unique family strengths without being asked.

The family should be viewed as a whole and provided supportive care. Throughout the ICU stay, which encompasses POD, patients and their family members tend to have unrestricted and more real visits than simple video calls. After POD, patients and family members require early family support to adapt to new responsibilities to be fulfilled in their family roles.

INTRODUCTION

Surgery is a critical point in a patient's life, but recovery does not end once the procedure is over. 1 , 2 Post‐operative delirium (POD) is a common complication that affects between 5% and 53.3% of post‐operative patients, 3 , 4 leading to poor short‐ and long‐term outcomes. 5 Unlike intensive care unit (ICU) delirium, besides the locational characteristic of not being restricted to occurring in the ICU, 6 POD can occur in various settings and is typically triggered by surgery and anaesthesia, usually within five days post‐surgery. 3 , 7 , 8 Notably, post‐operative patients with an ICU transfer show a higher incidence of POD and longer hospital stays than non‐intensive care patients. 9 , 10 , 11 Meanwhile, in critical care populations, compared with non‐surgical ICU patients, outcomes for patients in post‐operative transfer contexts tend to be poorer, especially for those developing POD, 12 , 13 , 14 which leads to more ICU events, including higher rates of unplanned extubation, physical restraints, and sleep deprivation. 15 POD in the ICU is a predictor of hospital stay, mortality and long‐term functional decline. 9 , 11 , 16 , 17 , 18 Improving patient prognosis has become a research priority because of changes in the bio‐psychosocial medical model. 19 , 20 Identifying the needs of at‐risk populations may facilitate targeted interventions. 21 Given the good evidence on the management of POD outside the ICU from existing measures, 9 , 22 , 23 but the difficulty of managing POD in the ICU, which affects patients and their families, 24 a research perspective also suggested that the focus should be on the at‐risk patients with POD in the ICU. 25 Moreover, there is also a growing emphasis on the function of the family support system. 26 Patient‐and family‐centred care (PFCC) has been widely promoted in the health care system 27 and is defined as an approach that respects the needs of each family. 28 , 29 Currently, the evidence‐based ABCDEF bundle care related to reduced delirium in the ICU has been proposed, where, ‘F’, family engagement and empowerment has been included as part of the prevention and treatment of delirium, highlighting the role of the family in supporting many aspects of delirium care. 30 , 31 Nevertheless, despite these, few previous studies have focused on the POD in the ICU or have simultaneously explored the need‐related experiences of patients and their families.

The significance of this study is that it provides first‐hand information on the dualistic worlds of patients and family members, identifying their dyadic needs in the light and shadows of their dyadic experiences, which may be beneficial for building high‐quality POD management in the ICU and transitional care.

BACKGROUND

Delirium is a form of acute brain dysfunction defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5). 7 Additionally, POD is a syndrome meeting DSM‐5 diagnostic criteria and characterized by acute and non‐specific disturbances of attention, cognition and sleep–wake cycle, occurring up to five days after surgery with clearly identified potential precipitating causes (i.e. anaesthesia and surgery). 3 , 7 , 8 Although an increasing number of studies have focused on the epidemiological features, pathogenesis, prevention and treatment of POD, 4 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 there has been no significant reduction in the incidence of POD in hospitalized patients. 3 , 4 Therefore, POD still needs to be addressed. 3 , 41 Patients with POD suffer from ongoing harm, including an increase in post‐operative complications, in‐hospital mortality, prolonged hospitalization and long‐term outcomes, such as a decrease in cognitive function, mental health and daily activities. 3 , 18 , 42 , 43 , 44 Some patients still recall their experiences of POD after discharge, even one year later, which has a negative impact on their quality of life 45 , 46 , 47 , 48 , 49 and their families. 50

Therefore, early management of POD is important; however, its pathophysiology and effective interventions remain uncertain. 51 As this situation is related to consciousness, 52 attention must be paid to the fact that the contents and outcomes of interventions may not fully correspond to the needs of patients and their families, 49 , 53 and qualitative research can describe such thoughts by providing potentially rich insights. 54 , 55 , 56

Little is known about the experience of POD in the ICU; however, the incidence of POD in the ICU is 15.6%–73%, which is higher than that in other wards and may lead to worse outcomes. 9 , 15 , 16 , 25 , 57 , 58 , 59 Previous studies have primarily reported patients' experiences with POD‐related hallucinations from a single‐view perspective, 45 , 46 , 60 , 61 , 62 , 63 , 64 with relatively limited studies on the overall experiences of both patients with POD in the ICU and their family members. According to the family stress theory, 56 as the patients' main dependents, family members may suffer a greater burden, which may even lead to psychological sequelae. 65 The construction of diseases can rarely be separated from the background of family life around patients; as such, only considering patients' solo experiences is incomplete. 66 Practising the PFCC theory is a core goal of critical care 67 , 68 ; therefore, effective interventions are required to simultaneously adhere to the beliefs of patients and their families. However, there is a gap in the literature regarding the dyadic experiences of patients with POD in the ICU and their family members. Insights into these experiences will be beneficial for shaping the future of POD care. Therefore, to address this knowledge gap, this study aimed to synthesize the dyadic experiences of patients with POD and their family members, along with the stance of participants and witnesses in the ICU, which is beneficial for exploring the subtle and specific needs that are not well identified. The researcher used herself as a research tool to gain insights into their dyadic needs in the light and shadows from their dyadic experiences, which could provide ICU nurses with information that could be used to facilitate targeted management for post‐operative patients at risk for delirium, which could also improve the well‐being of their family members.

AIMS AND OBJECTIVES OF STUDY

This study explores the dyadic experiences of patients with POD in the ICU and their family members to uncover their dyadic needs.

DESIGN AND METHODS

This study used a qualitative descriptive research design based on the philosophical foundation of naturalistic enquiries. 69 , 70 This research method is used to provide results synonymous with the direct meaning of data or events. 71 This study directly described experiences through a low‐inference interpretation; thus, this method was appropriate. Face‐to‐face semi‐structured interviews were analysed using thematic analysis. 72 The results were reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ). 73

Setting and sample

This study was conducted in three mixed ICUs of a tertiary hospital. Each ICU had an average of 25 beds and more than 1000 post‐operative patients each year. POD is diagnosed using the DSM‐IV and identified with a positive score by trained bedside nurses using the Confusion Assessment Method for the Intensive Care Unit (CAM‐ICU), a validated POD screening tool. 3 , 7 CAM‐ICU screening was started within 24 h of surgery and was performed at least three times per day during patients' ICU stay after surgery. POD data, including POD occurrence and duration, was extracted and measured from electronic nursing records, and the ICU and hospital length of stay (LOS) data was extracted and measured from cases. The ABCDEF Bundle had become part of clinical nursing practice. 30 , 74 However, there still exists a gap between the existing and best practice as recommended by the guidelines, 75 , 76 mainly in the inadequate implementation of the ‘F’, which represents family engagement and empowerment.

This study included two sets of participants: patients and family members. To be eligible for study participation, patients had to be transferred to the ICU after surgery and be recorded with POD in the ICU. Family members were identified based on patients; they had to be relatives of patients who were transferred to the ICU after surgery and recorded with POD in the ICU. POD screening data for post‐operative patients in the ICU were recorded in the electronic nursing record, and the researchers searched the electronic nursing record and followed these patients eligible to participate in the study until their discharge from the hospital. The inclusion and exclusion criteria are shown in Table 1 . Purposive sampling was used to recruit participants. 77 Potential participants were contacted for recruitment and gave their consent via the distributed informed consent forms after they or their relatives were transferred out of the ICU to the general wards. The sample size was determined using an information power model, which refers to the richness of the information provided by the samples and mainly depends on the study's purpose, sample specificity, existing theory, quality of dialogue and analysis strategies. The richer the information the sample provides and the more relevant it is to the study, the smaller the required sample size. 78 To obtain sufficient information power, 1 according to the study's purpose, this study required to increase the sample size appropriately 2 ; according to the sample specificity, this study recruited various patients such as those with different types of surgeries and various family members such as those with different relationships with the patients 3 ; according to the existing theory, the support of established theories can lead the study to explain the relationships and roles of the different dimensions of experience information more comprehensively, this study used the PFCC theory 4 ; according to the quality of dialogue, although the interviewer had received training from experts in interviewing and had established good partnerships with the participants in advance, the quality of the dialogue may not be as high as it should be because the interviewer was a novice interviewer and had less experience, the sample size required increasing to obtain a richer set of information 5 ; according to the analysis strategies, this study required more participants because it was a cross‐case descriptive analysis. Combined with the above five points, this study may require a larger sample size, and during the study, we continually assessed the sufficiency of the sample size and valued the adequacy and richness of the sample information.

Data collection tools and methods

An interview outline with open‐ended questions was constructed based on literature search, professional advice and pre‐interviews (Appendix A ). Three female researchers, one postgraduate nursing student and two clinical nursing specialists with master's degrees systematically studied the theoretical knowledge of qualitative research before the study. The postgraduate nursing student conducted the interviews; she had received training in interviewing and had established rapport with the participants. Given the clarity of memories, interviews were generally conducted within the first week, once or twice, after patients were discharged from the ICU. 5 , 6 Each interview lasted for 30–60 min. Meanwhile, at the timepoint of the interview was about to begin, the interviewer confirmed that patients were free of POD with the assistance of CAM‐ICU screening by a trained nurse, had no psychoactive drugs by reviewing patients' cases, and solicited the participants' consent once again. Considering that these patients still needed to be monitored and carry drain tubes such as intraperitoneal drain tubes or urinary catheters, their bedsides were chosen as the preferred places for interviews. To ensure as much privacy as possible, U‐shaped curtains were drawn, and interviews were conducted whenever feasible in the afternoon when there were few nursing operations, or when the patients in the next bed were not in the wards. The interviewer used face‐to‐face semi‐structured interviews to collect data, combining different techniques such as listening, questioning and responding to increase the depth of the interview and closely recorded non‐verbal information such as expressions, emotions and body language. 79 The interviews were audio‐recorded with the consent of the participants and transcribed within 24 h. Notes were taken to adjust the interview strategies over time. Additionally, the word ‘confuse’ would be used for participants unfamiliar with the term ‘delirium’. The same interviewer conducted the interviews to ensure the consistency of the recorded data. The interviewer was neutral to avoid imposing ideas on participants due to biases. Each pair of patients and family members were interviewed separately to avoid the responses of one patient or family member influencing or limiting the responses of the other, and to facilitate each participant's comprehensive understanding of the interview's focus. 80 Participant recruitment, interviews and data analysis were conducted simultaneously to help researchers identify data saturation. Data saturation was reached when the forty‐first interview (17 patients and 19 family members) ended with no new themes appearing. Two further interviews were then conducted with one patient and his family members to reconfirm the results, and the additional interviews revealed no new themes. The end of the recruitment and data collection, when no new themes appeared, was defined as information saturation.

Data analysis

The first researcher independently coded the data using the six‐phase process of thematic analysis proposed by Braun and Clarke, 72 aided by NVivo 12 software (QSR International). After framing the analysis report, the data and codes were reviewed by two other researchers. The authors met for discussion until a consensus was reached on all topics. All languages were translated into English and back into Chinese by an investigator proficient in English to ensure the original meaning.

The trustworthiness of the findings was assessed based on four dimensions 81 : For credibility, peer reviews were conducted to provide feedback on the study; data triangulation was achieved by asking the same interviewee questions repeatedly in different ways or contexts during one interview, as well as against verbal and non‐verbal behaviours. 82 For transferability, face‐to‐face in‐depth interviews were used to maximize the opportunity to meet diverse participants and collect extensive descriptions. The methods section of the study was described in detail to allow readers to assess how well the data may be applied to other studies. Each step of the data collection and analysis was systematically recorded through the researcher's log to form an audit trail 83 , 84 so that expert reviewers could check the dependability and confirmability of the study. Additionally, the researcher's short internship improved credibility, while the controlled discussion of POD issues with participants prevented researcher biases. 85

ETHICAL AND RESEARCH APPROVALS

This study was approved by the Clinical Research Ethics Committee of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University on 11 May 2023 (no. 20230218) and adhered to the principles of the Declaration of Helsinki. All participants voluntarily signed informed consent forms, including soliciting consent from participants to access clinical data such as POD and LOS data needed in this study before data collection. The researchers voluntarily committed to the principle of confidentiality by informing patients and family members that under no circumstances would identifiable information such as their names and identities be revealed. All participant data were protected and anonymized for privacy and confidentiality and archived in password‐protected files, and only the investigators had access to audio recordings and transcripts.

FINDINGS

Sample characteristics

The final sample consisted of 18 pairs of patients and their family members and two other family members who were involved in patient care, even though their sick relatives were unable to participate because of serious medical conditions. Five patients initially agreed but later declined to participate because of a lack of time. None of the participants reported cognitive impairments. Descriptive data of the participants are presented in Table 2 .

Main Findings

Theme 1: The dyadic relationship between patients and family members must be understood in the context of their shared emotional and behavioural experiences

In family systems, a closely bound dyadic relationship existed between patients and family members. Under the changed situation of the crisis of POD in critical settings presenting challenges for patients and their families, the complementary roles among family members were pronounced, and they influenced each other's emotions and behaviours, from which they spoke of the importance of family presence and family support.

Subtheme 1: Close ties to family in body and mind

After undergoing a series of stressful events from surgery and ICU transfer, as a dyadic system, patients and families jointly experienced the challenges of family‐related loneliness and distress due to separation. For patients, unplanned ICU admission after surgery can cause potential physical and psychological trauma, and the unsettling external environment and internal anxiety may lead to their increased vulnerability. Family is a basic social support resource for patients, and during this critical period of post‐operative ICU transfer, patients' need for family belonging and emotional support became more sensitive and desperate. However, the inability to contact families owing to physical separation in space over extended periods led to an outbreak of negative emotions, even developing feelings of abandonment. Considering the increased insecurity of patients in this context, some patients and their families believed that POD would subside or would not occur in cases of extended family presence, and might lead to an improvement in the patients' poor treatment adherence due to POD. Although face‐to‐face interactions were the most preferred, video‐call visitation, a mode of communication currently more likely to be widely implemented in ICUs, was also proven to improve patients' mental status by family members.

This situation (POD) would have subsided if I had my family to talk to in the ICU. (P1) She could not always see me in the ICU, so she might have panicked, and that was what caused this (POD)… (FM1)

After accompanying him in the ICU, I felt he was less irritable…His positive emotions were mobilized after I showed him videos of his grandchildren. (FM13)

In the ICU, I thought my son was going to abandon me; I wanted him to stay with me. (P15) He had been in the ICU since the surgery, so he probably felt that we did not care about him and were going to abandon him. (FM15)

He resisted taking medicine because he was delirious several times. When I was at his bedside, his mood stabilized, and he cooperated to take medicine. (FM19)

Surgery and intensive care may distort the patient's perception of reality. The family was an important element in the patient's latent consciousness refraction even during POD. This was reflected; on the one hand, patients recalled scenes of living with their families, and such hallucinations or dreams were usually related to the patient's early family life and relatives' experiences. Nonetheless, one patient and his family member said that when he found himself lying in the ICU, the strong sense of contrast had a negative impact. On the other hand, it was reflected in the fact that in the distressed illusory world where medical staff were regarded as imaginary enemies and the ICU became a shackle space during POD, family was perceived by patients as giving them the strength to survive. As reported, patients longed to be ‘rescued’ by family members. The emotional bond of family could span illness and circumstances, and the comfort to patients from family was irreplaceable.

The people (medical staff) in the ICU were cruel to me and treated me like garbage; I would die from their torture. I wanted my daughter to save me, and I was saying I wanted to go home. (P3) The doctor called me and said she insisted on going home. (FM3)

I dreamt I was farming with relatives in my hometown; I was happy (laughed)…At the time, I thought it was true, but later, I woke up and found I was tied up (restrained); I knew it was fake, and I felt lost. (P15) He was happy when he dreamed, only to wake up and realize that some family members in his dream had passed away… (F15)

Subtheme 2: Family as a community of common destiny to bear the burden of POD

The patients and families jointly bore the emotional and caring burdens caused by POD as the family was emphasized as a system interacting with one another.

POD became a topic of shared heaviness and silence among families, and their mental loads interact with each other. Patients suffered the greatest psychological shock from POD, with one patient even developing a stress reaction to surgery and ICU; along with descriptions of disconnection, helplessness, and loss of identity, they showed a strong decline in self‐identity and the resulting shame made them avoid mentioning the topic of POD. As a dyadic system, patients' unexpected emotional and behavioural changes from POD could be transferred to increased anxiety and terror in families. From surprise to unacceptability to enduring it alone, family members also experienced strong and alternating feelings of distress, and such mental loads seemed to reach a higher level especially if they were unable to recognize the patient who became unfamiliar to them behind these changes. Nevertheless, to avoid the transfer of their mental loads to patients, family members maintained a balance between downplaying patients' POD memories and unravelling the confusion of patients' changes.

I feel incredible, and I can't accept how I could have hallucinations…I didn't mention more to my families (shook head and took a heavy sigh) (P14) I was afraid to mention such hallucinations because I was worried that it would be bad for his health if he remembered it (POD). I hoped he would forget. (FM14)

The surgery took a heavy toll on her mood. She had a stress reaction when she saw people wearing the same blue colour as the ICU nurses…I was sad and in denial; I needed to adjust my mood…she was gentle before, but I felt as if she had become a different person (FM20)

Neither patients nor family members seemed willing to admit that only they or their family members experienced POD and thus became the weird ones; they did not want to be classified as a strange dyadic group. From their perspective, if POD were not rare and did not become an intractable medical problem or oddity because of its rarity, this would give them comfort, from which they could regain confidence in symptom recovery. Their descriptions implied a longing for external peer support, which was attributed to an internal fear of the unknown POD.

I believe I am certainly not the only one with this problem (POD); there must be quite a few others. (P18)

The man in the next bed being transferred from the ICU was just like him; repeating over and over that it was horrible inside the ICU. (FM2)

After POD, future lives and transitional care perspectives for families were uncertain. POD not only affects patients but also families with inseparable and responsible relationships. When discharge from the hospital was mentioned, several family members showed increased anxiety about the long‐term effects and recurrent risk of POD, particularly when some patients had already been found to have memory deterioration. Meanwhile, besides critical illness and surgery, the cognitive changes in patients with POD made them more stressed about their family's future lives because they perceived themselves as the main bearers of family transitional care and realized that they might take greater caring risks due to POD, which might affect family operation and their family roles. Faced with new realities and a seemingly troublesome family situation in the future, they bore uncertainty.

My memory must have changed a little bit now (agitated). (P10) I am worried about whether there will be a more significant change in her memory and cognition, and whether these current changes will be reversible…I am not sure what the long‐term effects of POD will be… (FM10)

What I am mostly worried about is that if his future life will be affected, my life will be affected too, and I will be more tired from caring for him… (FM13)

Theme 2: Family's history may predispose patients to POD

The occurrence of POD was often puzzling for a family. The joint tracing of predisposing triggers of POD through patients' self‐analysis and family members' knowledge of patients' experiences revealed that POD may associated with the patient's family history, such as family members' ICU death and family responsibilities, which may help health care providers dig deeper into the mechanisms of family‐related POD triggers and preventive measures accordingly.

Subtheme 1: Death of family members as a trigger for POD

Negative memories of the ICU, especially when combined with the elements of death and family, were identified as possible triggers for POD. For some patients, witnessing their family members dying in the ICU was a psychological trauma, which might push post‐operative ICU admissions to be more overwhelming for them; from their family members' perspectives, based on their knowledge of the patient's personal or relational characteristics, the shadowy experience might have triggered POD. One patient confirmed concerns about dying in the ICU on his own, which was consistent with his family's analysis.

I had witnessed her (the patient's wife's) dad die in the ICU, so I kept thinking about it repeatedly. I was terrified that no one would save me, and I might die there as well… (P2) He witnessed the whole process of my dad dying from the ICU, so he had a shadow. He might think about it, leading to this (POD)…he told me, ‘In the ICU, I thought that was how your dad died here. (FM2)

His mother died in the ICU; this shadow may have led to this situation (POD). When he was transferred to the ICU, he might also have been afraid of not being able to get out. (FM13)

Subtheme 2: Unbreakable family responsibilities

Undergoing surgery and ICU transfer disrupt family functioning. Patients often empathized with their family members; some felt that their admission to the ICU would impose a financial burden on their families, and some felt guilty for being unable to contribute to the family because of deep‐seated family responsibilities. From patients' perspectives, such ideological dilemmas may result in poor sleep, strange dreams, and mood swings related to POD. The family roles that patients perceived themselves as assuming, such as elders and partners, and the strength and quality of their relationships with their families might influence the formation of such ideological dilemmas due to family responsibilities.

I thought about my grandchildren in the ICU; I was supposed to be responsible for taking care of them and their future. So, I dreamed that her (daughter's) dead dad pulled these grandchildren to me… (P3)

He said he thought about the high cost incurred, so he had mood swings in the ICU. (FM4)

I thought hospitalization in the ICU would cost a lot of money, putting significant pressure on my husband; I could not sleep well when thinking about these… (P6)

Theme 3: Family engagement may prevent the development of POD

In the ICU, Family‐Integrated Care has been introduced; however, there is still a gap between theory and practice. It was found that although family members were not mandated to engage in POD care, their thoughts and behaviours already indicated a potential awareness and ability to engage in it, which reflected a possible role for family engagement in POD prevention.

Subtheme 1: Family members' initiatives to pay attention to the patient's state of consciousness, summarizing coping strategies, and making prevention recommendations along with patients for POD

POD increases vulnerability in critical post‐operative patients and is an ongoing process. Families already showed active motivation to engage in the care of their relative's POD, although they might not have realized this. Family members were acutely concerned about their relative's different states of consciousness, and actively sought help from different perspectives. Further to this, some family members understood and summarized coping methods from the patients' perspectives, believing that they could comfort patients through kinship because of their unique understanding of the patient's personality, personal knowledge, communication habits, needs and preferences, which might optimize the caring experience for patients with POD.

He said nonsense about not being in the hospital, then I showed him the quilt with the hospital's name on it, and he said, ‘I know’. If I directly denied it to him, he would be confused…I think this (POD) is a situation where relatives need to explain to him and tell him jokes. (FM2)

She (patient) was irritable and did not even remember I called her…the medical staff said it might be because her metabolism was slow after anaesthesia, but I immediately asked the doctor to check her brain…She might experience POD (judged)… (P6)

Prevention is also important. Both patients and family members offered diverse perspectives on POD prevention, focusing mainly on reducing the impact of the highly stimulating ICU environment. They highlighted the importance of a humanized architectural layout, including the provision of separate spaces for patients to prevent them from being negatively influenced by other critical patients, as post‐operative patients tend to be more sensitive after their transfer to the ICU. Additionally, the settings clarifying temporal orientation were also suggested as a possible positive method of reducing stimulation. These perceptions coincide with the existing delirium prevention measures. Furthermore, some family members suggested external devices as potentially beneficial in reducing POD, with recreational device resources perceived as relaxing for patients but highlighted as needing personalization; communication device resources were perceived as supporting connectivity between families and the enclosed ICU environment, and might therefore provide positive family support for patients.

She (patient) could not see the clock in the ICU, so she could not tell day from night and slept all day. (FM1)

I wish there would be a window over there (ICU) to feel the fresh air outside. However, that window must be small enough that no one can jump from it. (P10) Putting the video inside the ICU allows her to see us and may help prevent her hallucinations, right? (FM10)

When he suddenly found that the patients in the next bed were missing, he became frightened and asked me, ‘Are they dead?’ this has a significant negative impact on patients…Nurses gave him a radio as a tool for relaxation, but I think it was not feasible… he could not tune in to the channels, and what he heard might not be of interest; instead, it became a murmur, and he immediately rejected it. (FM13)

Subtheme 2: Lack of nurse–patient communication mediators—family members

From the participants' perspectives, if family members served as mediators to assist in nurse–patient communication, it would be possible to observe patients' POD care enhanced by family engagement. Medical staff were stated as the main communicators for patients in the ICU. In the case of poor communication between nurses and patients due to dialect, family members proactively thought this could be the cause of POD because patient's needs are not understood well, aggravating the patients' uneasiness about their illness and making them close themselves off; therefore, family members were recommended as communication mediators. In addition, in contrast to remaining silent to nurses due to stigma, patients were more willing to discuss POD experiences with family members; therefore, family members gave patients the courage to face POD and were potential communication mediators for medical staff and patients about the reality of POD.

If nurses speak Mandarin and my daughter then translates to me, I can understand. (P6) She is used to communicating in her dialect, so she could not communicate well with the medical staff and know about her illness; she was insecure…I wish to visit the ICU more often to assist with the communication problem. (FM6)

I did not ask nurses about hallucinations; if I did, they would be afraid of me… I told my son about this condition (POD)…Even if it (POD) occurs again, my family will be sympathetic. (P10)

Theme 4: Inadequate communication between health care providers and patients or families may negatively affect POD outcomes

Inadequate uptake of information and unhumanized communication strategies became common themes.

Before POD, most of the patients and families lacked a prior understanding of POD. Nurse–family communication focused on the results of disease and surgery rather than the POD; therefore, because of the lack of better comprehension of the POD, patients and families lost control over the reasonable expectation of their/their relatives' outcomes (that POD may occur) and thus leading to an increase in anxiety and uneasiness as they coped with POD occurrence, including the patient's refusal to communicate with the nurses owing to the uncertainty and the fear of being poorly understood.

After POD, its health education was still lacking. Most of the patients and families still have not even heard of the term POD and just assumed that they or their relatives were experiencing an unusual and confusing time in the ICU after surgery. Moreover, POD was considered secondary to the primary concerns of the patient's surgical and survival outcomes; it was considered merely as a state of mind rather than a symptom, or as a natural consequence of critical surgery that was only temporary; this might relate to the under‐emphasis of the severity and importance of POD when nurses communicated information about POD consequences to patients and families. However, it was noteworthy that several patients and family members already showed a desire to learn more about POD, including its definition, causes and process. Meanwhile, the necessity of timely and accurate communication of the patient's POD condition from medical staff was also emphasized by families, which was perceived to affect their provision of timely family support to patients, as well as their nursing quality evaluations.

I could not imagine how that (POD) happened (agitated)…Before surgery, we had thought this hospitalization would be easier, including himself…Until the nurse handover after ICU transfer, I did not hear he had experienced such (POD) in the ICU; I could not believe I had not been informed before (angered)… (FM2)

I had not known this (POD) would happen before the surgery, and I felt astonished…This (POD) is just a situation, that's all…ICU nurses told me that patients like him were more or less prone to this kind of situation (POD) and they would recover (FM5)

I did not bother to ask the nurse what this hallucination was about, I just had such a condition (POD)… (P10)

I was mainly worried about the success of surgery before…compared to psychological changes which are easier to recover from; physical recovery is important. (FM11)

No one told me before the surgery that I would be delirious; I was shocked. (P13) What does delirium mean? Does it mean gibberish or paranoia? (FM13)

Nurses' flexible communication strategies were essential, and they should communicate patients' POD conditions to families in a respectful manner. As some family members were sensitive to patients' abnormal mental health manifestations, they needed humanized communication, such as being listened to and receiving honest and hopeful information from nurses in an empathetic way rather than responses without considering their mental toughness. Unidirectional communication by nurses with their own perspectives could confuse families and stimulate conflicts between them.

Nurses did not believe me, and what they said was too absolute (angry). They said, ‘Don't you believe it? Your husband may suddenly jump off the building.’ I wondered whether my husband's personality was known to them; he was just introverted and now a little irritable, not depressed…I did not want to talk with these nurses. I did not believe what they said. (FM2)

DISCUSSION

This study aimed to explore the dyadic experiences related to POD in the ICU of patients and family members. The findings revealed four themes supported by six sub‐themes, adding new dimensions to the literature regarding patients and families and providing more comprehensive information for needs exploration.

The dyadic relationship between patients and family members must be understood in the context of their shared emotional and behavioural experiences

Critical situations such as surgery and ICU transfer could promote a strengthened representation of family relationships, and family bonds are often found to be an effective way to break through difficult situations. 46 , 63 , 86 According to family systems theory, family members are interrelated and interdependent through a dynamic network of relationships. 87 , 88 This indicates that family presence during the induction period of POD is significant, as a retrospective cohort study suggested that post‐operative family presence potentially reduced the incidence of POD in ICU patients. 89 Additionally, our study revealed that an index of dependence on family during POD may be related to the closeness of family relationships, and patients who expressed a desire for family presence also had family members who could understand their innermost thoughts. Therefore, nurses' advanced knowledge of family patterns must be incorporated into subsequent interventions. During POD, new insights have revealed that, families connect the time of patients' life trajectories. Although a few patients enjoy the illusory world of family where love exists after facing the reality of the ICU, it is important that future research focuses on the number of patients who experience a strong sense of contrast and whether this sense induces more severe POD. Family members should not only be defined as visitors but also as important members who play special roles in patient recovery. Family presence is an important moderator in achieving positive POD outcomes, 90 which cannot be achieved without the support of ICU visitation policies. Although restrictive visiting policies are predominantly used in ICUs worldwide, 91 , 92 flexible visitation policies are associated with a lower risk of delirium in ICU patients. 93 , 94 , 95 , 96 Furthermore, this study summarizes specific views on the possible forms and content of family presence. This includes the preference for face‐to‐face visitations, but in the ICU, video‐call visitation methods still have the chance to be promoted as an alternative if the realism effect is improved. 97 , 98 These opinions make subsequent interventions more targeted. However, balancing the relationship between family companionship under a flexible visiting system and hospital management, such as infections and the burden on nurses, still needs further exploration. It is also worth considering whether the electronic vehicles of virtual family visits could induce or exacerbate POD by making the patient feel that the real and virtual are unclear.

The occurrence of POD in post‐operative critical patients is a crisis situation according to the definition of situational crises, 99 it causes the patient's personal negative emotional experiences, affecting their recovery confidence. Meanwhile, it disrupts the normal functioning of the patient's family system; when the rapid changes in patients' personalities and behaviours cause terror and uncertainty among family members, 100 , 101 the family is unable to find solutions through the available resources, and therefore family functioning is threatened. 102 , 103 Faced with impending changes in family roles and responsibilities because of POD, family members reported confusion in seeking a balance between taking on the burden of transitional family care and ensuring their own quality of life. One unanticipated finding was that family members in parent–child relationships with patients were usually under greater pressure, which might stem from conflicts between the culture of filial piety and middle‐young people's life pressures. Families may have difficulty adapting to the new normal of their future life after a crisis. 104 Therefore, in the future, multidisciplinary teams, including critical care and surgical teams, should organize early training in transitional care focusing on the recovery of POD. First, they should conduct joint counselling sessions and provide training in stress management to help patients and families build emotional resilience, and second, they should support families with professional family caring skills in preventing post‐ICU syndrome caused by POD. 104 , 105 Furthermore, families who have previously experienced POD can record videos of their POD experiences, including transitional care, which may form an online resource library that enhances the confidence of other families in their recovery through peer support. The ideal effect of family support is that it will enable patients and families to transition from a difficult situation of pain and confusion to a new situation of reformulating the self. 106 However, specific support strategies need to be further explored based on patient and clinical practice, including whether they can facilitate the post‐traumatic growth of personal and family relationships to maintain the stability of family functions and promote family resilience.

Family's history may predispose patients to POD

Identifying the triggers of POD is the key to prevention, and it is noteworthy that some participants perceived that the occurrence of POD might be related to family experiences. This new finding was derived from a trusted dualistic dialogue that may provide new ideas for complementing POD triggers. 3 , 15 , 107 The disease trajectory of a living individual is co‐constructed by the diverse group formed by the patient and their family. 66 The emotional shock of witnessing the deaths of family members may deepen the patient's perceived risk levels, which, when facing their disease contexts, tend to catalyse a higher sense of vulnerability, and thus may negatively impact POD. 108 These findings imply that nurses should purposely intersperse topics related to patients' family experiences and identify possible stressors when communicating with family members upon their transfer to the ICU. This will help nurses prepare personalized care for POD prevention matched with stressors, 109 such as personalized psychological communication. Furthermore, spiritual care for post‐operative patients with high levels of family perceived risk in the ICU may be meaningful when they believe that they are on the verge of death. 110

Family engagement may prevent the development of POD

Although the clinical practice of family engagement in POD care in the ICU is still in its infancy, the family members in this study demonstrated the ability to identify and manage POD. A possible explanation for this may be that family members are more familiar with their sick relatives, so they can perceive subtle changes in their behaviours and expressions that nurses may have overlooked. As experts on that particular patient, 111 families seem to have the knowledge not only to recognize the patient's situation but also to provide practical and potential coping methods translated through family strengths. 112 Future PFCC should emphasize the recognition and use of family strengths, 113 strengthening family capacity building to better achieve family engagement through family empowerment, 114 in a way to improve the quality of POD care. 30 Patients with delirium tend to establish dependent relationships with ICU nurses, 115 but nurse – patient communication sometimes faces challenges such as dialects. Importantly, possibly based on family cohesion, 103 , 116 family members maintained greater responsibility, indicating a desire to be involved as mediators in the communication process rather than simply being bystanders. In addition, family members were preferred over nurses to be trusted options for patients to confide in the truth about POD experiences; this finding further suggested that family engagement might assist nurses in refining the trajectory of POD development in patients by obtaining detailed POD information from patients through family members acting as nurse–patient communication mediators. In contrast to the starting point of previous quantitative studies exploring the impact of family engagement on POD, 117 , 118 this study was conducted in the absence of preconceived notions of family engagement. However, the findings reflect the fact that family engagement in POD care has potential advantages from a humanitarian perspective along with subjective initiatives.

In future POD management, the clinical use of family engagement and empowerment should be strengthened. Furthermore, the advice of families should be widely solicited for clinical adaptation, which will facilitate the provision of care aligned with the needs of patients and increase family members' sense of self‐worth. Simultaneously, expanding nurses' learning about family engagement may help organizations develop better policies for POD management.

Inadequate communication between health care providers and patients or families may negatively affect POD outcomes

According to initial interaction theory, people tend to seek information to reduce their uncertainty, 119 and a vicious circle of information sharing may negatively affect patients and families. If patients are informed in advance of the possibility of cognitive or behavioural changes, they may be less affected by POD. If family members are provided with delirium information, it could facilitate mental preparation and family decision‐making 120 and support symptom management in family care. Therefore, POD education should be emphasized and incorporated into routine perioperative health education in future nursing management. Additionally, ICU doctors and nurses should maintain frequent communication with families about the patient's POD condition, which can prevent families from being overburdened and facilitate the creation of coherent memories and understanding within a patient's family, thus stabilizing dynamic family relationships. 121 , 122

Furthermore, POD is unique because of its fluctuating mental state, and there is a difference between how family members want to receive information and how nurses subjectively perceive the information to be delivered. Information sharing should not further exacerbate uncertainty and anxiety among family members. 109 Therefore, nurses should strengthen family‐centred communication, assess the characteristics and health literacy of family members, and seek matched information delivery methods; meanwhile, based on being fully aware of the consequences of POD, nurses should also seek a balance in communication strategies between considering the sensitive emotions and acceptance of patients and families and making them realize that POD should be valued, which will benefit long‐term health and care outcomes for patients and families.

LIMITATIONS

This study has some limitations. First, the single‐centre recruitment might have affected transferability, although the participants were from different areas, and this study was based on the well‐known perspective of PFCC. Second, patients were confused during POD; thus, some descriptions might not have been complete, resulting in recall bias. The findings might have been biased by participants' selective reporting because of unpleasant POD experiences. Third, few elderly patients could only communicate in a dialect; thus, their family members had to translate, which might have affected the interactivity of communication.

IMPLICATIONS AND RECOMMENDATIONS FOR PRACTICE

Furthermore, to facilitate clinical POD management, the strategies under the PFCC with new dimensions from the perspective of direct stakeholders – family are important. Future research should focus on different POD subtypes to develop more accurate interventions.

CONCLUSION

This study provides a holistic view of the evolving trajectory of POD in the dualistic world of patients and family members. Furthermore, patients and family members experience complex physical and psychological suffering because of POD. More real family‐accompanied visitations than videos, flexible communication, recognized family engagement and early comprehensive family support have become dyadic needs. These findings provide practical insights for empirical clinical research on POD. It is crucial that, although patients and their family members are independent individuals, they build each other's worlds together, as their disease perceptions and understanding are intertwined based on strong family networks. Considering this, in the future care of patients with POD, family solidarity and support should be fulfilled through family engagement and communication, which will help them build confidence and abilities to challenge the crisis situation of POD. Additionally, nurses should focus not only on patient care but also on holistic nursing for the family, enhancing earlier support to help the family develop resilience under the adversity of POD and promote post‐traumatic family functional stability.

AUTHOR CONTRIBUTIONS

Dong Jing: Conceptualization, Methodology, Software, Formal analysis, Investigation, Resources, Data Curation, Writing – Original Draft, Writing – Reviewing and Editing, Project administration. Sui Weijing: Methodology, Software, Validation, Writing – Reviewing and Editing. Zhuang Yiyu: Methodology, Software, Resources, Validation, Writing – Reviewing and Editing, Supervision.

FUNDING INFORMATION

This research was supported by the Science and Technology Department of Zhejiang Province (LTGY24H090006).

INFORMED CONSENT

This study complied with the principles of the Helsinki Declaration. Informed consent was obtained from patients or family members before data collection.

Supporting information

Data S1. Supporting information.

Group 1: Patient participants: Semi‐structured interview guide

During the time in the ICU after surgery, in what situation did you realize that your current state was different from the usual? (Describe the context at that time.)

How did you feel and cope? When did this happen and how long did it last? What do you think are the possible reasons for this?

What was the attitude of the medical staff and family members towards you at that time? Have you discussed this experience with them?

Have you ever known the post‐operative delirium/confusion in the ICU? What do you think of it?

How do you feel these experiences have impacted your daily life?

In general, for patients who have had similar experiences to yours, what kind of support or assistance do you think they might need?

Group 2: Family member participants: Semi‐structured interview guide

What did the patient tell you about his/her life in the ICU? (Describe the context at that time.)

How do you perceive the patient's unusual behavioural manifestations or mental state during their time in the ICU after surgery? (Describe the context at that time.)

How did you feel and cope?

How do you feel about the attitude of medical staff towards this situation?

From your point of view, what kind of support or assistance did you and your family members need when facing this situation?

Have you ever known the post‐operative delirium/confusion in the ICU? What do you think of it?

How do you feel these experiences have affected the daily life of you and your family members? What do you think about future life?

Dong J, Sui W, Zhuang Y. Patients' and family members' dyadic experience of post‐operative delirium in the intensive care unit: A qualitative study. Nurs Crit Care. 2025;30(2):e13297. doi: 10.1111/nicc.13297

[Correction added on 1 July 2025, after first online publication: The order of the family names and given names of all the authors have been corrected in this version.]

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

REFERENCES

1. Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet. 2003;362(9399):1921‐1928. doi: 10.1016/S0140-6736(03)14966-5

2. Kehlet H. Enhanced postoperative recovery: good from afar, but far from good? Anaesthesia. 2020;75(Suppl 1):e54‐e61. doi: 10.1111/anae.14860

3. Aldecoa C, Bettelli G, Bilotta F, et al. Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence‐based and consensus‐based guideline on postoperative delirium in adult patients. Eur J Anaesthesiol. 2024;41(2):81‐108. doi: 10.1097/EJA.0000000000001876

4. Swarbrick CJ, Partridge JSL. Evidence‐based strategies to reduce the incidence of postoperative delirium: a narrative review. Anaesthesia. 2022;77(Suppl 1):92‐101. doi: 10.1111/anae.15607

5. Evered LA, Chan MTV, Han R, et al. Anaesthetic depth and delirium after major surgery: a randomised clinical trial. Br J Anaesth. 2021;127(5):704‐712. doi: 10.1016/j.bja.2021.07.021

6. Stollings JL, Kotfis K, Chanques G, Pun BT, Pandharipande PP, Ely EW. Delirium in critical illness: clinical manifestations, outcomes, and management. Intensive Care Med. 2021;47(10):1089‐1103. doi: 10.1007/s00134-021-06503-1

7. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders: DSM‐5. American Psychiatric Association; 2013.

8. Evered L, Silbert B, Knopman DS, et al. Recommendations for the nomenclature of cognitive change associated with anaesthesia and surgery—2018. Br J Anaesth. 2018;121(5):1005‐1012. doi: 10.1016/j.bja.2017.11.087

9. Kirfel A, Guttenthaler V, Mayr A, Coburn M, Menzenbach J, Wittmann M. Postoperative delirium is an independent factor influencing the length of stay of elderly patients in the intensive care unit and in hospital. J Anesth. 2022;36(3):341‐348. doi: 10.1007/s00540-022-03049-4

10. Tilouche N, Hassen MF, Ali HBS, Jaoued O, Gharbi R, El Atrous SS. Delirium in the intensive care unit: incidence, risk factors, and impact on outcome. Indian J Crit Care Med. 2018;22(3):144‐149. doi: 10.4103/ijccm.IJCCM_244_17

11. Abelha FJ, Luís C, Veiga D, et al. Outcome and quality of life in patients with postoperative delirium during an ICU stay following major surgery. Crit Care. 2013;17(5):R257. doi: 10.1186/cc13084

12. Vakayil V, Ingraham NE, Robbins AJ, et al. Epidemiological trends of surgical admissions to the intensive care unit in the United States. J Trauma Acute Care Surg. 2020;89(2):279‐288. doi: 10.1097/TA.0000000000002768

13. Li H‐R, Guo Y. High‐risk factors for delirium in severely ill patients and the application of emotional nursing combined with pain nursing. World J Psychiatry. 2024;14(7):1027‐1033. doi: 10.5498/wjp.v14.i7.1027

14. Cai S, Lv M, Latour JM, et al. Incidence and risk factors of PostopeRativE delirium in intensive care unit patients: a study protocol for the PREDICt study. J Adv Nurs. 2019;75(11):3068‐3077. doi: 10.1111/jan.14097

15. Chaiwat O, Chanidnuan M, Pancharoen W, et al. Postoperative delirium in critically ill surgical patients: incidence, risk factors, and predictive scores. BMC Anesthesiol. 2019;19(1):39. doi: 10.1186/s12871-019-0694-x

16. Veiga D, Luis C, Parente D, et al. Postoperative delirium in intensive care patients: risk factors and outcome. Brazi J Anesthesiol. 2012;62(4):469‐483. doi: 10.1016/S0034-7094(12)70146-0

17. Romanauski TR, Martin EE, Sprung J, Martin DP, Schroeder DR, Weingarten TN. Delirium in postoperative patients admitted to the intensive care unit. Am Surg. 2018;84(6):875‐880. doi: 10.1177/000313481808400635

18. To‐Adithep P, Chittawatanarat K, Mueankwan S, et al. Long‐term outcomes of delirium in critically ill surgical patients: a multicenter prospective cohort study. J Psychosom Res. 2023;172:111427. doi: 10.1016/j.jpsychores.2023.111427

19. Iwashyna TJ. Survivorship will be the defining challenge of critical care in the 21st century. Ann Intern Med. 2010;153(3):204‐205. doi: 10.7326/0003-4819-153-3-201008030-00013

20. Schwitzer E, Jensen KS, Brinkman L, et al. Survival ≠ recovery: a narrative review of post‐intensive care syndrome. Chest Crit Care. 2023;1(1):100003.

21. Wilson S, Sutherland E, Razak A, et al. Implementation of a frailty assessment and targeted care interventions and its association with reduced postoperative complications in elderly surgical patients. J Am Coll Surg. 2021;233(6):764‐775. doi: 10.1016/j.jamcollsurg.2021.08.677

22. Siddiqi N, Harrison JK, Clegg A, et al. Interventions for preventing delirium in hospitalized non‐ICU patients. Cochrane Database Syst Rev. 2016;3(3):CD005563.

23. Burton JK, Craig LE, Yong SQ, et al. Non‐pharmacological interventions for preventing delirium in hospitalized non‐ICU patients. Cochrane Database Syst Rev. 2021;7(7):CD013307.

24. Auriemma CL, Harhay MO, Haines KJ, Barg FK, Halpern SD, Lyon SM. What matters to patients and their families during and after critical illness: a qualitative study. Am J Crit Care. 2021;30(1):11‐20. doi: 10.4037/ajcc2021398

25. Ní Chróinín D, Alexandrou E, Frost SA. Delirium in the intensive care unit and its importance in the post‐operative context: a review. Front Med. 2023;10:1071854. doi: 10.3389/fmed.2023.1071854

26. Liput SA, Kane‐Gill SL, Seybert AL, Smithburger PL. A review of the perceptions of healthcare providers and family members toward family involvement in active adult patient care in the ICU. Crit Care Med. 2016;44(6):1191‐1197. doi: 10.1097/CCM.0000000000001641

27. F IFPA . Patient‐and Family‐Centered Care: Institute F P A F; 2021‐04‐07. https://ipfcc.org/about/pfcc.html

28. Davidson JE, Aslakson RA, Long AC, et al. Guidelines for family‐centered care in the neonatal, pediatric, and adult ICU. Crit Care Med. 2017;45(1):103‐128. doi: 10.1097/CCM.0000000000002169

29. Goldfarb MJ, Bibas L, Bartlett V, Jones H, Khan N. Outcomes of patient‐ and family‐centered care interventions in the ICU: a systematic review and meta‐analysis. Crit Care Med. 2017;45(10):1751‐1761. doi: 10.1097/CCM.0000000000002624

30. Marra A, Ely EW, Pandharipande PP, Patel MB. The ABCDEF bundle in critical care. Crit Care Clin. 2017;33(2):225‐243. doi: 10.1016/j.ccc.2016.12.005

31. Morandi A, Piva S, Ely EW, et al. Worldwide survey of the “assessing pain, both spontaneous awakening and breathing trials, choice of drugs, delirium monitoring/management, early exercise/mobility, and family empowerment” (ABCDEF) bundle. Crit Care Med. 2017;45(11):e1111‐e22.

32. Bramley P, McArthur K, Blayney A, McCullagh I. Risk factors for postoperative delirium: an umbrella review of systematic reviews. Int J Surg. 2021;93:106063. doi: 10.1016/j.ijsu.2021.106063

33. Mevorach L, Forookhi A, Farcomeni A, Romagnoli S, Bilotta F. Perioperative risk factors associated with increased incidence of postoperative delirium: systematic review, meta‐analysis, and grading of recommendations assessment, development, and evaluation system report of clinical literature. Br J Anaesth. 2023;130(2):e254‐e262. doi: 10.1016/j.bja.2022.05.032

34. Cai S, Li J, Gao J, Pan W, Zhang Y. Prediction models for postoperative delirium after cardiac surgery: systematic review and critical appraisal. Int J Nurs Stud. 2022;136:104340. doi: 10.1016/j.ijnurstu.2022.104340

35. Gong X‐Y, Hou D‐J, Yang J, et al. Incidence of delirium after non‐cardiac surgery in the Chinese elderly population: a systematic review and meta‐analysis. Front Aging Neurosci. 2023;15:1188967. doi: 10.3389/fnagi.2023.1188967

36. Hansen N, Krasiuk I, Titsch T. Neural autoantibodies in delirium. J Autoimmun. 2021;125:102740. doi: 10.1016/j.jaut.2021.102740

37. Noah AM, Almghairbi D, Evley R, Moppett IK. Preoperative inflammatory mediators and postoperative delirium: systematic review and meta‐analysis. Br J Anaesth. 2021;127(3):424‐434. doi: 10.1016/j.bja.2021.04.033

38. Zhang H, Lu Y, Liu M, et al. Strategies for prevention of postoperative delirium: a systematic review and meta‐analysis of randomized trials. Crit Care. 2013;17(2):R47. doi: 10.1186/cc12566

39. Avidan MS, Maybrier HR, Abdallah AB, et al. Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double‐blind, randomised clinical trial. Lancet. 2017;390(10091):267‐275. doi: 10.1016/S0140-6736(17)31467-8

40. Deiner S, Luo X, Lin H‐M, et al. Intraoperative infusion of dexmedetomidine for prevention of postoperative delirium and cognitive dysfunction in elderly patients undergoing major elective noncardiac surgery: a randomized clinical trial. JAMA Surg. 2017;152(8):e171505. doi: 10.1001/jamasurg.2017.1505

41. Moppett I. Postoperative delirium: more risk scores or more action? Age Ageing. 2024;53(5):afae095. doi: 10.1093/ageing/afae095

42. Austin CA, O'Gorman T, Stern E, et al. Association between postoperative delirium and long‐term cognitive function after major nonemergent surgery. JAMA Surg. 2019;154(4):328‐334. doi: 10.1001/jamasurg.2018.5093

43. Saczynski JS, Marcantonio ER, Quach L, et al. Cognitive trajectories after postoperative delirium. N Engl J Med. 2012;367(1):30‐39. doi: 10.1056/NEJMoa1112923

44. Yuan C, Timmins F, Thompson DR. Post‐intensive care syndrome: a concept analysis. Int J Nurs Stud. 2021;114:103814. doi: 10.1016/j.ijnurstu.2020.103814

45. Instenes I, Gjengedal E, Eide LSP, Kuiper KKJ, Ranhoff AH, Norekvål TM. “Eeight days of nightmares … ” octogenarian Patients' experiences of postoperative delirium after transcatheter or surgical aortic valve replacement. Heart Lung Circ. 2018;27(2):260‐266. doi: 10.1016/j.hlc.2017.02.012

46. Claesson Lingehall H, Smulter N, Olofsson B, Lindahl E. Experiences of undergoing cardiac surgery among older people diagnosed with postoperative delirium: one year follow‐up. BMC Nurs. 2015;14:17. doi: 10.1186/s12912-015-0069-7

47. Pollard C, Fitzgerald M, Ford K. Delirium: the lived experience of older people who are delirious post‐orthopaedic surgery. Int J Ment Health Nurs. 2015;24(3):213‐221. doi: 10.1111/inm.12132

48. Duppils GS, Wikblad K. Patients' experiences of being delirious. J Clin Nurs. 2007;16(5):810‐818. doi: 10.1111/j.1365-2702.2006.01806.x

49. Gallie L. Life after intensive care‐a journey into the unknown. Nurs Crit Care. 2023;28(4):482‐483. doi: 10.1111/nicc.12905

50. Meilak C, Biswell E, Willis R, Partridge J, Dhesi J. A qualitative exploration of the views of patients and their relatives regarding interventions to minimize the distress related to postoperative delirium. Int J Geriatr Psychiatry. 2020;35(2):230‐249. doi: 10.1002/gps.5241

51. Magni G, Bilotta F. Chapter 41 – postoperative cognitive dysfunction. In: Prabhakar H, ed. Complications in Neuroanesthesia. Academic Press; 2016:411‐427.

52. Bélanger L, Ducharme F. Patients' and nurses' experiences of delirium: a review of qualitative studies. Nurs Crit Care. 2011;16(6):303‐315. doi: 10.1111/j.1478-5153.2011.00454.x

53. Gajic O, Ahmad SR, Wilson ME, Kaufman DA. Outcomes of critical illness: what is meaningful? Curr Opin Crit Care. 2018;24(5):394‐400. doi: 10.1097/MCC.0000000000000530

54. Darbyshire JL, Greig PR, Vollam S, Young JD, Hinton L. I can remember sort of vivid people…but to me they were plasticine. Delusions on the intensive care unit: what do patients think is going on? PLoS One. 2016;11(4):e0153775.

55. Williams V, Boylan A‐M, Nunan D. Qualitative research as evidence: expanding the paradigm for evidence‐based healthcare. BMJ Evid Based Med. 2019;24(5):168‐169. doi: 10.1136/bmjebm-2018-111131

56. Lewin S, Glenton C, Lawrie TA, et al. Qualitative Evidence Synthesis (QES) for Guidelines: Paper 2 – Using qualitative evidence synthesis findings to inform evidence‐to‐decision frameworks and recommendations. Health Res Policy Syst. 2019;17(1):75. doi: 10.1186/s12961-019-0468-4

57. Pandharipande P, Cotton BA, Shintani A, et al. Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients. J Trauma. 2008;65(1):34‐41. doi: 10.1097/TA.0b013e31814b2c4d

58. Ali MA, Hashmi M, Ahmed W, Raza SA, Khan MF, Salim B. Incidence and risk factors of delirium in surgical intensive care unit. Trauma Surg Acute Care Open. 2021;6(1):e000564. doi: 10.1136/tsaco-2020-000564

59. Yamanoi T, Suzuki S, Kaku R, Morimatsu H. Prolonged double‐low time and the incidence of postoperative delirium in surgical ICU patients. Acta Med Okayama. 2023;77(2):161‐167. doi: 10.18926/AMO/65145

60. Amofah HA, Broström A, Instenes I, et al. Octogenarian patients' sleep and delirium experiences in hospital and four years after aortic valve replacement: a qualitative interview study. BMJ Open. 2021;11(1):e039959. doi: 10.1136/bmjopen-2020-039959

61. Cohen CL, Atkins KJ, Evered LA, Silbert BS, Scott DA. Examining subjective psychological experiences of postoperative delirium in older cardiac surgery patients. Anesth Analg. 2022;136:1174‐1181. doi: 10.1213/ANE.0000000000006226

62. Instenes I, Fridlund B, Amofah HA, Ranhoff AH, Eide LS, Norekvål TM. 'I hope you get normal again': an explorative study on how delirious octogenarian patients experience their interactions with healthcare professionals and relatives after aortic valve therapy. Eur J Cardiovasc Nurs. 2019;18(3):224‐233. doi: 10.1177/1474515118810622

63. Jung J, Jang S, Jo S, Lee S. Delirium experience of the intensive care unit patients. J Korean Acad Nurs. 2022;52(2):134‐143. doi: 10.4040/jkan.21240

64. Laitinen H. Patients' experience of confusion in the intensive care unit following cardiac surgery. Intensive Crit Care Nurs. 1996;12(2):79‐83. doi: 10.1016/S0964-3397(96)80994-3

65. Partridge JSL, Martin FC, Harari D, Dhesi JK. The delirium experience: what is the effect on patients, relatives and staff and what can be done to modify this? Int J Geriatr Psychiatry. 2013;28(8):804‐812. doi: 10.1002/gps.3900

66. Sakellariou D, Boniface G, Brown P. Using joint interviews in a narrative‐based study on illness experiences. Qual Health Res. 2013;23(11):1563‐1570. doi: 10.1177/1049732313508014

67. Heyland DK, Rocker GM, Dodek PM, et al. Family satisfaction with care in the intensive care unit: results of a multiple center study. Crit Care Med. 2002;30(7):1413‐1418. doi: 10.1097/00003246-200207000-00002

68. Connors AF, Dawson NV, Desbiens NA, et al. A controlled trial to improve care for seriously iII hospitalized patients: the study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA. 1995;274(20):1591‐1598. doi: 10.1001/jama.1995.03530200027032

69. Lincoln YS. Naturalistic Inquiry. Sage Publications; 1985:14‐16.

70. Polit DF, Beck CT. Essentials of Nursing Research: Appraising Evidence for Nursing Practice. Lippincott Williams & Wilkins; 2010.

71. Willis DG, Sullivan‐Bolyai S, Knafl K, Cohen MZ. Distinguishing features and similarities between descriptive phenomenological and qualitative description research. West J Nurs Res. 2016;38(9):1185‐1204. doi: 10.1177/0193945916645499

72. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77‐101. doi: 10.1191/1478088706qp063oa

73. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32‐item checklist for interviews and focus groups. International J Qual Health Care. 2007;19(6):349‐357. doi: 10.1093/intqhc/mzm042

74. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263‐306. doi: 10.1097/CCM.0b013e3182783b72

75. Hwang DY, El‐Kareh R, Davidson JE. Implementing intensive care unit family‐centered care: resources to identify and address gaps. AACN Adv Crit Care. 2017;28(2):148‐154. doi: 10.4037/aacnacc2017636

76. Ciufo D, Hader R, Holly C. A comprehensive systematic review of visitation models in adult critical care units within the context of patient‐ and family‐centred care. Int J Evid Based Healthc. 2011;9(4):362‐387. doi: 10.1111/j.1744-1609.2011.00229.x

77. Gill SL. Qualitative sampling methods. J Hum Lact. 2020;36(4):579‐581. doi: 10.1177/0890334420949218

78. Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016;26(13):1753‐1760. doi: 10.1177/1049732315617444

79. Marcus GE, Fischer MMJ. Anthropology as Cultural Critique: An experimental moment in the human sciences.. University of Chicago Press; 1999.

80. Eisikovits Z, Koren C. Approaches to and outcomes of dyadic interview analysis. Qual Health Res. 2010;20(12):1642‐1655. doi: 10.1177/1049732310376520

81. Guba EG, Lincoln YS. Fourth Generation Evaluation. Sage; 1989.

82. Denzin NK, Lincoln YS. Handbook of Qualitative Research. Sage; 1994.

83. Koh HMD, Lee CSC, Anna C, Lau Y. Perceptions and experiences of nurses transitioning to primary care: a qualitative study. Int Nurs Rev. 2022;69(2):201‐210. doi: 10.1111/inr.12691

84. Morse JM. Designing Funded Qualitative Research. Sage; 1994.

85. Dyar KL. Qualitative inquiry in nursing: creating rigor. Nurs Forum. 2022;57(1):187‐200. doi: 10.1111/nuf.12661

86. Koukouli S, Lambraki M, Sigala E, Alevizaki A, Stavropoulou A. The experience of Greek families of critically ill patients: exploring their needs and coping strategies. Intensive Crit Care Nurs. 2018;45:44‐51. doi: 10.1016/j.iccn.2017.12.001

87. Olsen EH. The impact of serious illness on the family system. Postgrad Med. 1970;47(2):169‐174. doi: 10.1080/00325481.1970.11697375

88. Bowen M. Family Therapy in Clinical Practice. Jason Aronson; 1993.

89. Mohsen S, Moss SJ, Lucini F, et al. Impact of family presence on delirium in critically ill patients: a retrospective cohort study. Crit Care Med. 2022;50(11):1628‐1637. doi: 10.1097/CCM.0000000000005657

90. Burns KEA, Misak C, Herridge M, Meade MO, Oczkowski S. Patient and family engagement in the ICU: untapped opportunities and underrecognized challenges. Am J Respir Crit Care Med. 2018;198(3):310‐319. doi: 10.1164/rccm.201710-2032CI

91. Dragoi L, Munshi L, Herridge M. Visitation policies in the ICU and the importance of family presence at the bedside. Intensive Care Med. 2022;48(12):1790‐1792. doi: 10.1007/s00134-022-06848-1

92. Yang H‐Y, Feng F, Yang W‐W, Chen Y. Application of a flexible visitation system in critically ill patients: a randomized clinical trial. Sci Prog. 2023;106(1):368504231165663. doi: 10.1177/00368504231165663

93. Bannon L, McGaughey J, Verghis R, Clarke M, McAuley DF, Blackwood B. The effectiveness of non‐pharmacological interventions in reducing the incidence and duration of delirium in critically ill patients: a systematic review and meta‐analysis. Intensive Care Med. 2019;45(1):1‐12. doi: 10.1007/s00134-018-5452-x

94. Nassar Junior AP, Besen BAMP, Robinson CC, Falavigna M, Teixeira C, Rosa RG. Flexible versus restrictive visiting policies in ICUs: a systematic review and meta‐analysis. Crit Care Med. 2018;46(7):1175‐1180. doi: 10.1097/CCM.0000000000003155

95. Westphal GA, Moerschberger MS, Vollmann DDA, et al. Effect of a 24‐h extended visiting policy on delirium in critically ill patients. Intensive Care Med. 2018;44(6):968‐970. doi: 10.1007/s00134-018-5153-5

96. Rosa RG, Tonietto TF, da Silva DB, et al. Effectiveness and safety of an extended ICU visitation model for delirium prevention: a before and after study. Crit Care Med. 2017;45(10):1660‐1667. doi: 10.1097/CCM.0000000000002588

97. Yuan C, Xiao Y, Wang F, Wang Y, Wang Y, Lin F. The effect of video visitation on intensive care unit patients and family members outcomes during the COVID‐19 pandemic: a randomised controlled trial. Intensive Crit Care Nurs. 2023;76:103394. doi: 10.1016/j.iccn.2023.103394

98. Pun BT, Badenes R, Heras La Calle G, et al. Prevalence and risk factors for delirium in critically ill patients with COVID‐19 (COVID‐D): a multicentre cohort study. Lancet. Respir Med. 2021;9(3):239‐250. doi: 10.1016/S2213-2600(20)30552-X

99. Caplan G. Principles of Preventive Psychiatry. Basic Books; 1964.

100. Mishel MH. Uncertainty in illness. Image J Nurs School. 1988;20(4):225‐232. doi: 10.1111/j.1547-5069.1988.tb00082.x

101. Matt B, Schwarzkopf D, Reinhart K, König C, Hartog CS. Relatives' perception of stressors and psychological outcomes – Results from a survey study. J Crit Care. 2017;39:172‐177. doi: 10.1016/j.jcrc.2017.02.036

102. McClowry SG. Family functioning during a critical illness: a systems theory perspective. Crit Care Nurs Clin North Am. 1992;4(4):559‐564. doi: 10.1016/s0899-5885(18)30603-8

103. Van Horn ER, Kautz D. Promotion of family integrity in the acute care setting: a review of the literature. Dimens Crit Care Nurs. 2007;26(3):101‐107. doi: 10.1097/01.DCC.0000267803.64734.c1

104. Hirshberg EL, Butler J, Francis M, et al. Persistence of patient and family experiences of critical illness. BMJ Open. 2020;10(4):e035213. doi: 10.1136/bmjopen-2019-035213

105. Renner C, Jeitziner M‐M, Albert M, et al. Guideline on multimodal rehabilitation for patients with post‐intensive care syndrome. Crit Care. 2023;27(1):301. doi: 10.1186/s13054-023-04569-5

106. Morse JM, Carter BJ. Strategies of enduring and the suffering of loss: modes of comfort used by a resilient survivor. Holist Nurs Pract. 1995;9(3):38‐52. doi: 10.1097/00004650-199504000-00008

107. Peng C, Wang M, Geng Y, et al. Risk factors for postoperative delirium in ICU patients with severe illness based on systematic review and meta‐analysis. Ann Palliat Med. 2022;11(1):309‐320. doi: 10.21037/apm-21-3954

108. Chalmers K, Thomson K. Coming to terms with the risk of breast cancer: perceptions of women with primary relatives with breast cancer. Qual Health Res. 1996;6(2):256‐282. doi: 10.1177/104973239600600207

109. Rückholdt M, Tofler GH, Randall S, Buckley T. Coping by family members of critically ill hospitalised patients: an integrative review. Int J Nurs Stud. 2019;97:40‐54. doi: 10.1016/j.ijnurstu.2019.04.016

110. Gualdani S, Pegoli M. Spirituality in health care: the role of needs in critical care. Trends Anaesthes Critic Care. 2014;4(6):175‐177. doi: 10.1016/j.tacc.2014.09.003

111. Wilson ME, Beesley S, Grow A, et al. Humanizing the intensive care unit. Crit Care. 2019;23(1):32. doi: 10.1186/s13054-019-2327-7

112. Sittner BJ, Hudson DB, DeFrain J. Using the concept of family strengths to enhance nursing care. MCN Am J Matern Child Nurs. 2007;32(6):353‐357. doi: 10.1097/01.NMC.0000298130.16914.47

113. Alemayehu YH. Enhancing patient and family‐centered care: a three‐step strengths‐based model. Int J Caring Sci. 2019;12(1):584‐590.

114. Dunst CJ, Trivette CM. Capacity‐building family‐systems intervention practices. In: Singer GHS, Biegel DE, Conway P, eds. Family support and family caregiving across disabilities. Taylor & Francis Group; 2014:33‐57.

115. Whitehorne K, Gaudine A, Meadus R, Solberg S. Lived experience of the intensive care unit for patients who experienced delirium. Am J Crit Care. 2015;24(6):474‐479. doi: 10.4037/ajcc2015435

116. Saunders JC. Family functioning in families providing care for a family member with schizophrenia. Issues Ment Health Nurs. 1999;20(2):95‐113. doi: 10.1080/016128499248691

117. Wang Y‐Y, Yue J‐R, Xie D‐M, et al. Effect of the tailored, family‐involved hospital elder life program on postoperative delirium and function in older adults: a randomized clinical trial. JAMA Intern Med. 2020;180(1):17‐25. doi: 10.1001/jamainternmed.2019.4446

118. Lin L, Peng Y, Huang X, Li S, Chen L, Lin Y. A family intervention to prevent postoperative delirium in patients undergoing cardiac valve surgery: a randomized controlled study. Heart Lung. 2023;63:1‐8. doi: 10.1016/j.hrtlng.2023.09.002

119. Berger CR, Calabrese RJ. Some explorations in initial interaction and beyond: toward a developmental theory of interpersonal communication. Hum Commun Res. 1974;1(2):99‐112. doi: 10.1111/j.1468-2958.1975.tb00258.x

120. Huang LJ, Tsai HH, Wang YW, Chou CL. Sailing in a sea of perplexity: family caregivers' experience of patients with delirium. Nurs Crit Care. 2022;27(1):73‐80. doi: 10.1111/nicc.12620

121. Wright LM, Leahey M. Nurses and Families: a Guide to Family Assessment and Intervention. FA Davis; 2005.

122. Lehmkuhl L, Munck MS, Rothmann MJ, Sorknaes AD. Exploring critically ill patients' and their relatives' experiences of intensive care unit during COVID‐19: a qualitative study. Nurs Crit Care. 2024;29(2):427‐437. doi: 10.1111/nicc.13011

Associated Data

Supplementary Materials

Data S1. Supporting information.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.