ABSTRACT Background Intensive care nurses encounter numerous ethical problems in clinical practice. When these morally challenging situations remain unresolved, they may lead to moral distress and moral injury among nurses and may ultimately result in quiet quitting behaviours. Studies examining the relationships among moral distress, moral injury and quiet quitting among intensive care nurses within a comprehensive model are limited. Aim This study aimed to examine the relationships among moral distress, quiet quitting and moral injury among intensive care nurses. Study Design The study employed a cross‐sectional correlational design. It was conducted between 1 April and 31 October 2025 among intensive care nurses working in a university hospital in Türkiye. The data were collected using the Nurse Introductory Information Form, the Moral Distress‐Appraisal Scale, the Moral Injury Symptom Scale–Healthcare Professional, and the Quiet Quitting Scale. The relationships among moral distress, moral injury, and quiet quitting were examined using the Pearson correlation coefficient. The statistical significance of the mediating effects was evaluated using 95% confidence intervals from 5000 bootstrap samples. Results The study included 138 intensive care nurses. A moderate positive relationship was found between moral distress and moral injury among intensive care nurses ( r = 0.524, p < 0.001). In addition, a low but statistically significant positive relationship was identified between quiet quitting and both moral injury ( r = 0.258, p < 0.001) and moral distress ( r = 0.201, p < 0.001). The mediation analysis revealed that moral injury played a full mediating role in the relationship between moral distress and quiet quitting (B = 0.083; 95% CI [0.003, 0.170]). Conclusion This study demonstrates that the relationship between moral distress and quiet quitting among intensive care nurses operates through moral injury. The findings indicate that moral injury constitutes a key mechanism that negatively affects nurses' professional engagement and organisational commitment. In this context, quiet quitting may be seen as an outcome arising from unresolved ethical problems. Strengthening ethical support mechanisms to prevent moral injury is therefore important for the professional sustainability of nurses. Relevance to Clinical Practice These findings highlight the clinical importance of recognising and addressing moral distress and moral injury among intensive care nurses, as early interventions targeting these ethical challenges may help reduce quiet quitting tendencies and support sustained professional engagement. Accordingly, strengthening ethical support mechanisms and improving working conditions may foster a more supportive clinical environment and help sustain nurses' engagement in intensive care practice.
ABSTRACT Background Building rapport, understood as establishing a meaningful and trusting relationship through interpersonal interactions between healthcare professionals and patients or their family members, was described in research as early as the 1960s. Although studies highlight its importance in clinical relationships, the concept remains largely undefined, with limited research on experiences of rapport among family members of intensive care unit patients. This concept analysis can help to provide conceptual clarity for future practice and research. Aim This paper aimed to analyse and define the concept of ‘building rapport’ with ICU family members. Study Design The concept analysis framework of Walker and Avant was used, following the systematic steps of identifying uses, attributes, antecedents, consequences and model cases. Data were obtained from Swedish and English dictionaries and peer‐reviewed articles identified through a systematic literature search and screening. Titles and abstracts were reviewed, and six studies were selected based on predefined inclusion and exclusion criteria. Results This analysis clarifies the previously undefined concept of building rapport from the perspective of ICU family members. Building rapport is characterized by empathy and mutual understanding. Key antecedents include communication, time and relationships, while consequences are increased trust and the development of a care partnership. An empirical referent is a shift from family members as passive recipients to active participants in care. Conclusions Key features of building rapport with ICU family members are empathy and mutual understanding, supported by communication, time and relationships. The findings suggest that rapport may facilitate family participation and care partnerships in intensive care. However, the findings should be interpreted in light of the limited empirical basis and the absence of formal quality appraisal. Relevance to Clinical Practice Clarifying the concept of building rapport may support communication training, reflective practice and active listening strategies that strengthen partnerships with ICU family members.
ABSTRACT Background Intensive care unit (ICU) delirium is a heterogeneous and fluctuating form of acute brain dysfunction. Binary classification may obscure underlying mechanisms and temporal patterns. Aim To identify clinical phenotypes and acute brain dysfunction trajectories among critically ill patients with delirium and examine their associations with clinical course indicators. Study Design This real‐world, longitudinal, electronic health record‐based retrospective cohort study included adults admitted to four ICUs in China from 1 January 2023 to 31 December 2025. Delirium was assessed three times daily and classified into four non‐mutually exclusive phenotypes: hypoxic, septic, sedative‐associated and metabolic. Longitudinal latent class analysis modelled normal brain function, delirium and coma across ICU Days 1–7. Multivariable models examined phenotype burden and trajectory class. Results Among 4284 eligible ICU patients, delirium was identified in 767 patients during the ICU stay. The most common phenotypes were sedative‐associated delirium (51.8%) and septic delirium (50.7%), with substantial overlap. Four trajectories were identified: early improvement (22.8%), persistent delirium‐fluctuating (68.4%), coma‐delirium transition (5.6%) and progressive coma‐dominant acute brain dysfunction (3.1%). Each additional phenotype was associated with longer ICU stay (adjusted geometric mean ratio [aGMR] 1.16, 95% confidence interval [CI] 1.09–1.23), hospital stay (aGMR 1.11, 95% CI 1.05–1.18) and mechanical ventilation duration (aGMR 1.57, 95% CI 1.37–1.79), but not with in‐hospital mortality (adjusted odds ratio 1.40, 95% CI 0.92–2.13). Coma‐related trajectories were associated with longer ICU stay and mechanical ventilation. Conclusion Phenotype‐trajectory profiling captured heterogeneity in ICU delirium and provides a descriptive framework for characterising its mechanisms and longitudinal course. Relevance to Clinical Practice Integrating overlapping phenotypes with longitudinal brain dysfunction patterns may help ICU nurses structure the assessment of reversible contributors and identify patients requiring closer monitoring.
ABSTRACT Background As Intensive Care Unit (ICU) survival improves, attention has shifted towards patients' psychological well‐being and recovery. Although Virtual Reality (VR) is increasingly used in critical care, patients' experiences of VR interventions have not been comprehensively synthesised. Aim To synthesise qualitative and mixed‐methods evidence regarding ICU patients' perceptions, experiences and implementation‐related considerations associated with VR interventions. Methods A qualitative systematic review and thematic synthesis following Thomas and Harden's three‐stage approach was conducted. Eight databases were searched from inception to September 2025. Studies employing qualitative methods or components of mixed methods exploring ICU patients' firsthand VR experiences were included. Methodological quality was appraised using the JBI checklist. Results Eight studies involving 247 participants were included. Four analytical themes were synthesised: (A) VR as a restorative escape, (B) VR as a route from passive endurance to active participation, (C) Patient readiness and personal preference shape VR engagement, and (D) VR as a co‐produced intervention requiring contextual and relational adaptation. Conclusions ICU patients perceived VR as a valuable tool that provided restorative escape and enabled active recovery, yet multiple barriers shaped its feasibility. Implementation should consider comfortable devices, customisable content and staff training. These findings inform patient‐centred VR design in the ICU. Relevance to Clinical Practice VR offers a non‐pharmacological approach that may support patient well‐being and recovery during an ICU stay. It can provide meaningful focus and relief from distress, while encouraging engagement with rehabilitation. Nurses play a key role in facilitating sessions and assessing patient readiness. Implementation may be enhanced by comfortable, bed‐compatible devices, customisable content and staff training. While not all patients may be suitable candidates, VR appears generally acceptable and could be integrated into individualised care plans. Review Registration The review protocol had been registered in PROSPERO (International prospective register of systematic reviews). The registration number is CRD420251074650.
ABSTRACT Background Intensive care units (ICUs) are high‐risk environments where nurses administer the majority of high‐alert medications, making them the final checkpoint in the medication‐use process. However, evidence on nurse‐led interventions specifically targeting high‐alert medication errors has not been systematically synthesized across all ICU populations. Aim This systematic review evaluated the effectiveness of nurse‐led interventions in reducing high‐alert medication errors in neonatal, paediatric and adult intensive care units and examined implementation strategies that enhance patient safety. Study Design We followed PRISMA 2020 guidelines. A comprehensive search was conducted in PubMed, Web of Science and Scopus for studies published between January 2000 and June 2026. Inclusion criteria required nurse‐led interventions, measurement of high‐alert medication error rates and critical care settings. The risk of bias was assessed. A narrative synthesis was performed due to heterogeneity in study designs and outcome measures. Results Six studies met the inclusion criteria. Interventions included simulation‐based training, staff education, smart pump integration, clinical decision support systems and standardization of medication orders and protocols. All studies reported improvements in medication safety outcomes, including reductions in medication error rates, improved compliance, enhanced accuracy and increased efficiency. Secondary outcomes included improved compliance with PRN orders (from 62.0% ± 9.2% to 77.7% ± 10.1%), reduced medication dispensing time (to < 1 min) and cost savings ($90 000–$130 000 per year). Risk of bias was moderate to low in five studies and high in one study. Conclusion Nurse‐led multicomponent interventions are associated with reductions in high‐alert medication errors and improvements in safety outcomes in critical care settings. However, technology alone is insufficient without workflow integration and nursing education. Education and standardization require concurrent process redesign for sustained improvement. Relevance to Clinical Practice Nurses should advocate for multicomponent strategies combining training, technology and standardized protocols. Healthcare organizations must ensure workflow integration to maximize the benefits of smart pumps and clinical decision support systems. Future research should employ rigorous designs, include diverse ICU settings and low‐ to middle‐income countries and evaluate long‐term sustainability.
