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      Psychological distress and morbidity of family members experiencing virtual visiting in intensive care during COVID-19: an observational cohort study


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          During the coronavirus disease 2019 (COVID-19) pandemic, intensive care units (ICUs) around the world introduced virtual visiting to mediate the psychological impact of in-person visiting restrictions. Our objective was to evaluate levels of distress, depression, anxiety, and stress among family members experiencing virtual visits.


          Multi-centre prospective observational study recruiting adult family members of critically ill patients in the United Kingdom (UK) using a bespoke virtual visiting solution (aTouchAway). We recruited participants and administered validated questionnaires digitally via their aTouchAway account. Prior to first virtual visit, participants completed the Distress Thermometer (score range 0–10) and the Depression, Anxiety and Stress Scale (DASS)-21. Following first and subsequent virtual visits, participants repeated the Distress Thermometer and completed the Discrete Emotions Questionnaire.


          We recruited 2166 adult family members of ICU patients in 37 UK hospitals. Most were grown up children (33%) or spouses/partners (23%). Most (91%) were ≤ 65 years. Mean (SD) pre-virtual-visit Distress Thermometer score was 7 (2.6) with 1349/2153 (62%) reporting severe distress. Pre-visit Distress Thermometer scores were associated with relationship type (spouse/partner OR 1.65, 95% CI 1.27–2.12) but not family member age, or length of ICU stay. Mean (SD) post-visit Distress Thermometer score provided by 762 (35%) participants was 1.6 (3.2) points lower than pre-visit ( P < 0.001). Of participants experiencing multiple visits, 22% continued to report severe distress. Median (IQR) pre-visit DASS-21 score was 18 (2–42) (1754 participants). Severe-to-extremely severe depression, anxiety, or stress were reported by 249 (14%), 321 (18%), and 165 (9%) participants, respectively. Participants reported a range of emotions with reassurance being the most common, anger being the least.


          Family members exposed to COVID-19 pandemic ICU visiting restrictions experienced severe distress. One fifth of family members reported severe-to-extremely sever anxiety or depression. Distress score magnitude and prevalence of severe distress decreased after undertaking one or more virtual visits.

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          Most cited references34

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          Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample.

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            Risk of post-traumatic stress symptoms in family members of intensive care unit patients.

            Intensive care unit (ICU) admission of a relative is a stressful event that may cause symptoms of post-traumatic stress disorder (PTSD). Factors associated with these symptoms need to be identified. For patients admitted to 21 ICUs between March and November 2003, we studied the family member with the main potential decision-making role. Ninety days after ICU discharge or death, family members completed the Impact of Event Scale (which evaluates the severity of post-traumatic stress reactions), Hospital Anxiety and Depression Scale, and 36-item Short-Form General Health Survey during a telephone interview. Linear regression was used to identify factors associated with the risk of post-traumatic stress symptoms. Interviews were obtained for family members of 284 (62%) of the 459 eligible patients. Post-traumatic stress symptoms consistent with a moderate to major risk of PTSD were found in 94 (33.1%) family members. Higher rates were noted among family members who felt information was incomplete in the ICU (48.4%), who shared in decision making (47.8%), whose relative died in the ICU (50%), whose relative died after end-of-life decisions (60%), and who shared in end-of-life decisions (81.8%). Severe post-traumatic stress reaction was associated with increased rates of anxiety and depression and decreased quality of life. Post-traumatic stress reaction consistent with a high risk of PTSD is common in family members of ICU patients and is the rule among those who share in end-of-life decisions. Research is needed to investigate PTSD rates and to devise preventive and early-detection strategies.
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              Psychological distress: concept analysis.

              The term 'distress' is frequently used in nursing literature to describe patient discomfort related to signs and symptoms of acute or chronic illness, pre- or post-treatment anxiety or compromised status of fetuses or the respiratory system. 'Psychological distress' may more accurately describe the patient condition to which nurses respond than does the term 'distress'. Psychological distress is seldom defined as a distinct concept and is often embedded in the context of strain, stress and distress. This creates confusion for nurses attempting to manage the care of people experiencing psychological distress. This paper is a concept analysis of psychological distress based on Walker and Avant's (1995) criteria that identifies the attributes, antecedents, and consequences of psychological distress based upon the findings of the literature review. In addition, empirical references are identified and constructed cases presented. A literature search was conducted using MEDLINE, CINAHL, Ovid, PsychINFO, and Cancer Lit databases over the last 50 years. The purposes of this concept analysis were: (1) to establish the concept of psychological distress as a clear and distinct concept, separate from strain, stress and distress, and (2) to provide nurses with a base of knowledge from which to plan effective clinical interventions. Content analysis of the literature revealed that, although used frequently in health care literature, the origin of the concept of psychological distress has not been clearly articulated and is ill-defined. Psychological distress is a serious problem faced by many of the people whom nurses encounter on a daily basis. An understanding of the concept of psychological distress will help nurses ameliorate this problem in patients. Nursing research related to the exploration of psychological distress is also needed.

                Author and article information

                Intensive Care Med
                Intensive Care Med
                Intensive Care Medicine
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                1 August 2022
                : 1-9
                [1 ]GRID grid.13097.3c, ISNI 0000 0001 2322 6764, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, , King’s College London, ; Rm 1.13, James Clerk Maxwell Building, 57 Waterloo Rd, London, SE1 8WA UK
                [2 ]GRID grid.13097.3c, ISNI 0000 0001 2322 6764, Cicely Saunders Institute, , King’s College London, ; London, UK
                [3 ]GRID grid.13097.3c, ISNI 0000 0001 2322 6764, Department of Psychology at the Institute of Psychiatry, Psychology and Neuroscience, , King’s College London, ; London, UK
                [4 ]GRID grid.5846.f, ISNI 0000 0001 2161 9644, University of Hertfordshire, ; Hertfordshire, UK
                [5 ]GRID grid.439624.e, ISNI 0000 0004 0467 7828, East and North Herts NHS Trust, ; Stevenage, UK
                [6 ]GRID grid.46699.34, ISNI 0000 0004 0391 9020, King’s College Hospital, ; London, UK
                [7 ]GRID grid.420545.2, ISNI 0000 0004 0489 3985, Guy’s and St Thomas’ NHS Foundation Trust, ; London, UK
                © Springer-Verlag GmbH Germany, part of Springer Nature 2022, Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

                This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.


                Emergency medicine & Trauma
                intensive care,psychological distress,family,virtual visiting,covid-19
                Emergency medicine & Trauma
                intensive care, psychological distress, family, virtual visiting, covid-19


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