June 29, 2020

An article review from the ESICM Journal Review Club

Effect of a Nurse-Led Preventive Psychological Intervention on Symptoms of Post-traumatic Stress Disorder Among Critically Ill Patients A Randomized Clinical Trial

The authors aimed to determine whether a nurse-led preventive and complex psychological intervention initiated in the ICU reduced patient-reported Posttraumatic Stress Disorder (PTSD) symptom severity at six months. A multi-centre parallel-group cluster-randomised trial was employed to address the study’s aims.

Critically ill patients who regained mental capacity were identified and approached for participation in the ICU, of which 1458 provided informed consent. Twenty-four ICUs were randomised 1:1 to the intervention or control group. Intervention ICUs (n = 12; 669 participants) delivered usual care during a baseline period followed by an intervention period.

The preventive, psychological intervention comprised promotion of a therapeutic ICU environment, three stress support sessions and a relaxation and recovery programme delivered by trained ICU nurses to ICU patients. Control ICUs (n = 12; 789 participants) delivered usual care in both baseline and intervention periods.

The PTSD symptom severity among survivors at six months was measured using the PTSD Symptom Scale–Self-Report questionnaire (score range, 0-51, with higher scores indicating greater symptom severity; the minimal clinically important difference was considered to be 4.2 points). The mean PTSD Symptom Scale–Self-Report questionnaire score in intervention ICUs was 11.8 (baseline period) compared with 11.5 (intervention period). In control ICUs, 10.1 (baseline period) compared with 10.2 (intervention period) between periods. There was no significant difference in PTSD symptom severity at six months.


This was a multi-centre, parallel-group; cluster randomised clinical trial, with integrated economic and process evaluations.

The trial utilised a stepped rollout approach, and it was conducted in 24 adult general ICUs.

ICUs were eligible if they were active participants in the ICNARC Case Mix Programme, which allowed for baseline performance assessment. A large, well-matched sample of 1,458 patients enrolled in the study. Moreover, 971 (58%) ICU nurses in the intervention ICUs attended a comprehensive 3-day training on the content and delivery of the stress support.

The programme was developed by a panel of senior experts in psychology, clinical education and critical care nursing.


The authors of the trial did acknowledge several limitations, such as challenges to deliver, as patients reported associating the intervention with a stigma of mental illness and challenges to initial approach for consent in the ICU.

The intervention was not blinded, and also there was loss of follow-up for the patient-reported primary outcome. Audio-recording of a sample of stress support sessions to assess fidelity was found to be intrusive and felt uncomfortable.

Training ICU nurses, rather than psychologists to provide intervention, might have introduced variance in the quality of complex intervention.

The total amount of interventions per patient was possibly sub-optimal, with 63.8% receiving three stress support sessions, 16.6% receiving two, 10.6% receiving one and 9% receiving no sessions of stress support intervention.



This unique study evaluated critically ill patients in the ICU and the effect of a nurse-led preventive, complex psychological intervention, as delivered in this trial. However, it did not significantly reduce patient-reported PTSD symptom severity at six months. Therefore, the findings of this trial do not support the use of a nurse-led preventive and complex psychological intervention.


This article review was prepared and submitted by Petra Polgarova, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, United Kingdom, on behalf of the ESICM N&AHP and Journal Review Club.

  1. Effect of a Nurse-Led Preventive Psychological Intervention on Symptoms of Posttraumatic Stress Disorder Among Critically Ill Patients: A Randomized Clinical Trial.
  2. Richards-Belle A, Mouncey PR, Wade D, et al; POPPI Trial Investigators. Psychological Outcomes following a nurse-led Preventative Psychological Intervention for critically ill patients (POPPI): protocol for a cluster-randomised clinical trial of a complex intervention.

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