Differential Perceptions of Noninvasive Ventilation in Intensive Care among Medical Caregivers, Patients, and Their Relatives: A Multicenter Prospective Study—The PARVENIR Study

SINCE the 1980s, noninvasive ventilation (NIV) has become a cornerstone therapy for acute respiratory failure. A large number of positive randomized trials^1–6  have led to a marked increase in the use of NIV,^7–9  even in extreme situations such as hypoxemic respiratory failure, elderly patients, immunocompromised patients, or palliative care.^6,10,11  Because it requires a close “partnership” between a conscious patient and the patient’s caregivers,¹²  namely intensive care unit (ICU) physicians and nurses, NIV is a distinctive treatment in the ICU. For nurses, NIV requires frequent interventions and may be time-consuming.¹³  It implies intense involvement, which is dependent on predisposing factors such as knowledge,¹⁴  perceptions,¹⁵  and beliefs.^16,17  Conflicts between caregivers’ personal beliefs and their own perception of care may impact the patient’s adhesion to care recommendations, communication, and empathy¹⁸  and, ultimately, jeopardize the patient’s quality of care (fig. 1).¹⁹  Patient cooperation is another cornerstone of NIV success. Pain,^20,21  dyspnea,²²  and discomfort generate suffering, which, in a life-threatening context, may challenge this cooperation. In addition, in an age when the patient’s family and next of kin are often present at the bedside to provide essential psychological support,^23–25  patient suffering and treatment may generate psychological distress.^26,27 

The perceptions of NIV stakeholders, especially nurses, have been poorly described to date.²⁸  Note that the term “noninvasive” was originally used to refer to positive pressure mask ventilation in contrast to “invasive” ventilation (use of an endotracheal tube), the complications, discomfort, and psychological burden of which have been extensively described.

Our general hypothesis was that the term “noninvasive,” its indisputable clinical benefits, and its related sensations may not be perceived in exactly the same way by patients, relatives, physicians, and nurses. The use of NIV may therefore be associated with adverse perceptions by patients and relatives, and adverse experiences for caregivers. We therefore conducted a survey among ICU physicians and nurses, patients, and their relatives with three main specific objectives: (1) to compare the perceptions of NIV by ICU physicians and nurses, in parallel to description of these same elements in patients and their relatives; (2) to explore factors associated with caregivers’ willingness to administer NIV; and (3) to focus on NIV-related patient and relative anxiety by identifying its main risk factors and potential ways of improvement.

We conducted a prospective multicenter study in French and Belgian adult ICUs during a 6-month period (December 2012 to June 2013), including junior and senior ICU physicians, nurses, patients, and their relatives. This study was approved by the appropriate legal and ethical institutions (Comité de protection des personnes Ile de France 6 and “Comite consultatif pour le traitement de l’information en matière de recherche dans le domaine de la santé,” Paris, France, A00104-37). Written informed consent to participate in the study was obtained from patients and relatives, whereas completion of the questionnaire was considered to indicate consent to participate for nurses and physicians.

Three specific questionnaires intended for ICU caregivers (i.e., physicians and nurses), patients, and their relatives, respectively, were designed. Questionnaire development followed three steps.

Questionnaire content was defined by a panel from two ICUs, including three senior ICU physicians experienced in NIV, research methodology, and qualitative research, one junior ICU physician, two psychologists, one head nurse, and four nurses.

For the questionnaire intended for ICU caregivers, the panel selected three domains deemed to represent the caregivers’ global perception of NIV in the ICU: (1) personal experience of management of a NIV session (including patient care, family care, doctor–nurse collaboration, and ICU environment), (2) ICU caregivers’ perception of the patient’s emotional experience during NIV, and (3) their own opinion/belief/perception and emotional experience of this treatment.

Similarly, the panel also created a patient questionnaire. As no data on the patient’s perception of NIV are currently available, patient questions were based on studies performed on invasive ventilation.^29–34  Questions regarding their perception of the devices, their environment, management of a NIV session, and their overall perception of care during their ICU stay were developed. Lastly, the relative questionnaire assessed their perception of the next-of-kin emotional experience during NIV.

The style and content of the physicians’ and nurses’ questionnaires were evaluated by four external ICU physicians and four external ICU nurses, respectively. Ten patients who had received NIV (but not only), and their relatives also accepted to evaluate the style and content of the respective questionnaires. Patients’ and relatives’ evaluations focused on the style and ease of understanding of the questionnaire. They were also specifically debriefed about the completeness of the questionnaire regarding NIV-associated management, NIV-associated perceptions, and NIV-associated feelings. If a NIV-associated perception or part of the NIV management was not addressed by the questionnaire and was reported by at least two patients or relatives, the missing item was then added to the questionnaire.

The final version of the nurses’ and physicians’ questionnaire was tested with 10 nurses and 6 physicians from two different ICUs. External approval by 10 patients and relatives showed overlapping memories between NIV and invasive ventilation with endotracheal tube. In order to maintain focus on NIV-associated perceptions and to avoid any overlap memories with other forms of ICU therapy, especially invasive mechanical ventilation, the steering committee decided to only include patients who had exclusively received NIV (i.e., who had not received invasive mechanical ventilation). Lastly, the final versions of the patient and the relative questionnaires were then approved by six patients who had only received NIV and six relatives, respectively.

Based on this process, a 45-item questionnaire assessing both the clinicians’ and nurses’ experiences and perceptions regarding overall NIV management was created (see detailed questionnaire in Supplemental Digital Content 1, http://links.lww.com/ALN/B272). This report describes the responses to a specific vignette as follows: “A 60-year-old male is admitted to your ICU with acute respiratory failure. At ICU admission, he is polypneic, sweating with cyanosis and tachycardia. Given the initial severity, noninvasive ventilation is started. You are the nurse/physician in charge of this patient.” The patient questionnaire comprised 30 items, while the next-of-kin perception of emotional experiences was investigated by 27 specific items concerning the ongoing ICU stay (see Supplemental Digital Content 1, http://links.lww.com/ALN/B272).

Whenever possible, similar items were used in the three respondent categories (i.e., caregivers, patients, and relatives). Each item relative to NIV perception was scored from 1 to 10 (with “1” corresponding to “not at all” or “never” and “10” corresponding to “certainly” or “always”).

A panel of 50 French and Belgian ICUs was selected. All ICUs either were members of the European network on mechanical ventilation (Reseau européen de recherche en ventilation artificielle) or had previously participated in a multicenter study on NIV.^7,35  Thirty-two ICUs (64%) agreed to participate in this study. Their characteristics (type of ICU, number of beds, number of ICU physicians, patient–nurse ratio, regular nurse–physician meetings, written NIV procedure, and nurse work shift durations) and their activities (number of ICU admissions, number of intubated patients, and number of NIV patients per year) were collected. In addition, physician and nurse personal characteristics (including age, sex, number of years working in ICU) were collected. Lastly, the main patient demographic characteristics, severity at ICU admission scores, smoking status, length of ICU stay, duration of NIV, and reason for NIV were recorded.

All ICU nurses and physicians (including juniors) working in each participating ICU were invited to fill in a questionnaire, regardless of the type of patient they were managing at the time they received the questionnaire. In each participating ICU, a designated local medical investigator targeted physicians, whereas the head nurse was in charge of collecting questionnaires from the nursing staff. Physicians’ and nurses’ questionnaires were collected over a 2-month period. Patients and their relatives were screened for inclusion at ICU discharge. Patients were included when they were more than 18 yr of age, had received NIV for more than 4 h during their ICU stay, and had not been intubated before or after NIV. To minimize the effect of specific medical conditions and to enhance the quality of responses, patients were excluded when they were unable to read or understand French, had received home mechanical ventilation before ICU admission, or presented delirium, as assessed by the Confusion Assessment Method for the ICU (CAM-ICU).^36,37  Relatives (e.g., family members, partners, or close friends) of included patients were recruited when they were able to read and understand French, had visited their relatives at least once during a NIV session, and were more than 18 yr of age. Only one relative per patient was recruited to avoid overrepresentation of a single family.

Perceptions of NIV among ICU physicians, ICU nurses, patients, and their relatives were compared. This analysis focused on identifying predictive factors of willingness of caregivers to administer NIV and patients’ and relatives’ anxiety in relation to NIV, as these factors are clinically relevant and may be amenable to improvement. To achieve these goals, “willingness to use NIV” was defined as a respondent score of greater than or equal to 6/10 to the specific item “are you willing to care for the patient depicted in the vignette?” Similarly, an anxious perception of NIV was defined as a score of greater than or equal to 6/10 on the item “did you feel anxious during NIV?” (patient questionnaire) or “did you feel that your relative was anxious during NIV?” (relative questionnaire).

Data were initially assessed for normality. Continuous normally distributed variables were compared using Student’s t tests or ANOVA, while nonnormally distributed variables were compared using Wilcoxon rank sum tests or Kruskal–Wallis tests. Data were expressed as median (interquartile range) or mean ± SD. Categorical variables were compared using chi-square test for equal proportions or Fisher exact tests and were reported as numbers (percentages). A Bonferroni adjustment for multiple comparisons was used for pairwise comparisons of perception of NIV by caregivers, patients, and relatives.

Multivariate logistic regression was used to identify factors independently associated with the caregivers’ willingness to use NIV in the ICU and major anxiety induced by NIV as perceived by patients and relatives, with results expressed as odds ratios (95% CI). Multivariate models were constructed using both stepwise selection and backwards elimination techniques. All variables with a univariate P value less than 0.05 were considered for model inclusion. The area under the receiver operating characteristic curve (AUC) and its standard error (SE) were used to examine the ability of the model to discriminate between (1) caregivers who reported willingness to administer NIV and those who did not, and (2) patients and relatives who reported major anxiety during NIV and those who did not. To correct for optimism and to internally validate the model, the model was repeatedly fitted with 1,000 bootstrap samples to calculate the mean AUC.

Analyses were performed using SAS version 9.3 software (SAS Institute Inc., USA), and a two-sided P value of 0.05 was considered to be statistically significant.

Completed questionnaires were received from 311 ICU physicians (response rate 91%) and 752 ICU nurses (response rate 62%) working in 32 ICUs (response rate 64%) (fig. 2). Details of participating ICUs are given in table 1, and table 2 reports physician and nurse characteristics. Fourteen (45%) centers reported having a written NIV procedure (table 1).

Twenty ICUs returned completed questionnaires for 396 patients (simplified acute physiology score II 36 [28 to 42]) and 145 relatives (fig. 2). Main patient and relative characteristics are described in table 3. Briefly, 57% of patients who survived NIV were male and received NIV for a median of 2 (1 to 5) days for acute on chronic respiratory failure (67%) or de novo acute respiratory failure (33%). NIV was provided without sedation or opioid infusion in all centers. Thirty-two percent had previously experienced NIV, and 22% had been intubated before this ICU stay.

Noninvasive ventilation perceptions among ICU physicians, nurses, patients, and their relatives are reported in figure 3 (also see Supplemental Digital Content, table 1, http://links.lww.com/ALN/B272), which shows major discrepancies between categories, as nurses generally reported more negative feelings and more frequently regretted providing NIV than other categories (P < 0.05), despite strong recognition of its efficacy (fig. 3). By contrast, relatives were poorly convinced about the efficacy of NIV (“NIV is an effective treatment”). Although only 56% of physicians and 32% of nurses had ever tried NIV on themselves, NIV was more frequently considered to be a stressful treatment (“do you think NIV is a stressful treatment?”) or a traumatic experience (“do you think NIV is traumatic experience?”) by caregivers than by patients and relatives (P < 0.05). Although all included patients were discharged from the ICU after receiving NIV (i.e., study design), 34% of patients and 25% of their relatives reported regrets about having received NIV versus having received simple oxygen therapy or having been intubated (i.e., score greater than 1).

One hundred and eight (64%) ICU physicians and only 241 (32%) ICU nurses reported high willingness to administer NIV (see Supplemental Digital Content, figs. 1 and 2, http://links.lww.com/ALN/B272). Physician and nurse characteristics according to their willingness to administer NIV are reported in table 4. Independent factors associated with willingness to administer NIV among physicians were NIV case-volume, the belief that NIV is an effective treatment, and the feeling of being competent to provide NIV (table 4). In nurses, “feeling competent to provide NIV” and “feeling valuable or proud in providing NIV” were facilitating factors, while “working 12-h shifts,” “feeling that care of a NIV patient is excessively time-consuming,” and a negative perception of this therapy (e.g., “it is an aggressive device,” “it makes patients suffer,” “feelings of regret in relation to NIV”) were barriers to willingness to administer NIV. The AUC for the model was 0.72 (SE, 0.3) and 0.74 (SE, 0.2) for physicians and nurses, respectively. The mean AUC after bootstrap resampling increased marginally to 0.75 ± 0.03 and 0.77 ± 0.02 (table 4).

The characteristics of patients and their relatives according to major NIV-induced anxiety are shown in the table 5. When interviewed about “the anxiety associated with a NIV session,” 149 (37%) patients and 65 (45%) relatives reported a high level of anxiety (see Supplemental Digital Content, figs. 3 and 4, http://links.lww.com/ALN/B272). “Dyspnea during NIV,” “long NIV session,” and “the need to have someone at the bedside” were identified as independent risk factors of high anxiety in patients (table 5). Similarly, “seeing their next of kin experiencing difficulties to make themselves understood” was independently associated with a higher level of anxiety in relatives, whereas receiving “clear explanations” was a protective factor. None of the patient characteristics (e.g., demographic, reason for NIV, past experience of NIV, etc.) were associated with anxiety during NIV session for either patients or relatives. Lastly, the mean AUC of the model after bootstrap resampling was 0.87 ± 0.02 and 0.75 ± 0.05 for patients and their relatives, respectively.

The main results of this study can be summarized as follows: (1) overall perceptions of NIV were significantly different among ICU nurses, ICU physicians, patients, and their relatives; (2) two out of three ICU nurses described low willingness to perform NIV, which is associated with working 12-h shifts in ICU and a negative perception of NIV; (3) one out of three ICU patients and one out of two relatives perceived NIV as a very stressful experience that generates anxiety; and (4) most factors associated with low willingness to administer NIV by nurses or anxiety in patients and relatives may be amenable to change and therefore constitute potential targets of improvement. To our knowledge, this is the first large-scale study to describe the perceptions of caregivers, patients, and relatives regarding NIV as a specific treatment modality in the ICU.

Only 64% of physicians and 32% of nurses reported willingness to administer NIV. This contrasts with the numerous studies that have demonstrated the benefit of NIV in various causes of acute respiratory failure over the last 2 decades,^1–6  and with the fact that both nurses and physician were very convinced that NIV was “an effective therapy.” This finding is also surprising in view of the various surveys that have observed a growing use of NIV in the ICU, especially in France, where the current study was mainly performed.^7,8  It is noteworthy that the willingness of physicians to administer NIV was associated with NIV case-volume.³⁸  Not only is case-volume associated with a better prognosis in invasively and noninvasively mechanically ventilated patients,^38,39  but it also reinforces the caregiver’s personal experience, which makes them more comfortable and confident with the technique. In addition, mastering NIV management takes time, but eventually allows the treatment of more severely ill patients, resulting in an expected improvement of the success rates.^40,41  Improving caregivers’ feelings of being competent involves various interventions, such as educational programs and local guidelines, including written procedures.^42,43  It is noteworthy that written procedures were available in less than half of centers, a lower rate than previously reported.^28,44 

Two determinants of low willingness of nurses to administer NIV were related to ICU structural characteristics, excessive NIV-related workload, and working 12-h shifts. Workload is directly related to the patient-to-nurse ratio, which was 2.5 in our study, a relatively higher level than those commonly observed in other Western European countries, Northern Europe, and North America.^45,46  A low patient-to-nurse ratio improves patient safety^45,47,48  and quality of care^49–52  and increases time available to communicate with the patient and his/her family,⁵³  which results in higher levels of family satisfaction in ICU.⁵⁴  It should also be noted that NIV-related workload is higher for nurses than for physicians, which may explain why willingness to administer NIV was lower among nurses. In addition, when not rewarded by improvement of the patient’s condition, this gap between intense involvement requiring a high workload and failure of treatment¹⁹  may lead to “loss of belief in the efficacy of NIV” and result in “regrets.” This is particularly true since nurses are more likely to perceive inappropriateness of care¹⁹  and are consequently more acutely aware of the suffering of their patients than physicians.^55–57 

Most determinants of low willingness to administer NIV are amenable to change, allowing willingness improvement strategies. For instance, showing nurses that their patients’ experience of NIV is less traumatic and less stressful than they imagine and that patients are less likely to regret NIV than nurses may help to improve the nurses’ willingness to administer NIV.

Patients receiving invasive ventilation are subject to numerous stressful experiences, which are associated with spells of terror, feeling nervous when left alone, and poor sleeping pattern.⁵⁸  In addition, pain, feeling tense, anxiety, inability to speak/communicate, lack of control, and nightmares have been constantly reported as important patient complaints on invasive mechanical ventilation.^22,30–33  However, patients’ recollections of their NIV experience in ICU have been poorly studied. Because anxiety has been frequently reported in relation to mechanical ventilation^22,30–33  and could be a major goal of improvement,²²  we focused our analysis on NIV-induced anxiety in patients and their relatives. Again, we found that most of these risk factors were amenable to change and could therefore constitute potential targets for improvement.^11,12 

Some factors, such as dyspnea and length of NIV sessions, are influenced by the physician’s prescriptions. Dyspnea associated with invasive mechanical ventilation may be related to inadequate ventilator settings and may be dramatically reduced by improving ventilator settings.²²  Reduction of identified ICU stressors is warranted to decrease NIV-induced anxiety, and new tools such as medical hypnosis or sophrology might help to achieve this goal.^59,60  Similarly, NIV sessions should not be longer than needed and should be reduced as soon as the patient’s condition improves. Lastly, target-controlled infusion of propofol or remifentanil during NIV in patients with NIV failure due to poor tolerance may facilitate acceptance of NIV and could therefore decrease NIV-related anxiety.^61,62 

Patients with NIV-induced anxiety expressed the need to have beside support and to share their experience with their relatives. An open visiting policy could meet this expressed need.^23–25  Such a policy may be part of a larger family-centered care policy,^63–65  which must include the quality of information given to the relatives of a patient receiving NIV, as poor-quality information is a source of anxiety. In addition, as demonstrated in patients dying in ICU,⁶⁶  simple, standardized written information on NIV could also improve communication with relatives.⁶⁷  Trying NIV themselves might be a simple first measure for caregivers to experience this therapy and to therefore provide more objective information to patients and relatives regarding the disadvantages and the sensations to be expected with NIV.

It is noteworthy that 34% of patients reported regrets at having NIV, which were independent predictors of high anxiety. This finding highlights the negative impact of NIV-induced anxiety, which makes patients paradoxically regret having received a treatment that was potentially beneficial. This result is all the more surprising in that 32% of patients had a previous experience of NIV, and should therefore have been better prepared for these sensations.

This study presents several limitations. First, we defined a high level of willingness and a high level of anxiety based on suggestions from a panel of practicing ICU physicians and nurses. The subjective threshold of high willingness and high anxiety used in our study may therefore be open to criticism. In addition, the 10-point scale used in the questionnaire with, consequently, no “neutral answer” may also have influenced the results. Second, because of intercultural differences, discrepancies between ICU organizations,^68–70  and a wide range of NIV use reported worldwide,²⁸  our findings may not be relevant to every ICU around the world. As an example, NIV is a medical prescription applied by nurses in many European countries, whereas a team including respiratory therapists, physicians, and nurses manage NIV in the United States and Canada. However, the study was performed in university- and non–university-affiliated hospitals in France (and Belgium), suggesting that this may reflect real-life practices in French-speaking countries. Third, because CAM-ICU assessment was performed at study inclusion and not daily during the ICU stay, we can only rule out patients who did not exhibit delirium at the time they were asked to answer the questionnaire. However, patients who had a normal CAM-ICU at inclusion could have exhibited delirium during previous NIV sessions. Fourth, we cannot rule out that education level and social status of the patients, which were not collected, might have influenced NIV perceptions. Fifth, our inclusion criteria were restricted to patients with successful NIV in order to avoid overlapping memories between invasive ventilation and NIV. Previous studies have suggested the existence of overlapping memories in intubated patients after NIV failure. We could therefore speculate that the perception of NIV would have been even poorer if patients who failed NIV had also been included. However, we do not know how this factor would have influenced the discrepancies between the various categories. In addition, less than half of the relatives answered the questionnaire, as most of them did not visit their relatives during a NIV session (fig. 2). Finally, NIV-related perceptions were not compared to perceptions related to another ICU therapy, such as invasive mechanical ventilation, oxygen therapy, or renal replacement therapy.

Although promising results of the use of high-flow oxygen for the treatment of acute respiratory failure have recently been published,⁷¹  NIV is still the leading treatment option for acute on chronic respiratory disease and cardiogenic pulmonary edema. Most of the factors related to a lack of willingness for caregivers and high anxiety for patients and relatives are amenable to change. Better management of these risk factors could therefore help to improve the management of a potentially traumatic experience. Based on these findings, there is a strong rationale to encourage ICU nurses and physicians to improve their knowledge of NIV by means of specific training programs. These training programs could focus on (1) improving the technical aspects of NIV management (improve the skills of ICU physicians and nurses), (2) early detection and management of patient discomfort, and (3) providing better information concerning the risks, benefits, and expected sensations of NIV.

The authors are indebted to all intensive care unit physicians and intensive care unit nurses of the PARVENIR study group who participated in the study (see list in the appendix). The authors also thank Christian Delafosse, M.D., Department of Respiratory and Intensive Care Medicine, Groupement Hospitalier Eaubonne, Montmorency Hôpital Simone Veil, Eaubonne, France, for his humor column on noninvasive ventilation, which was the source of this work.

Dr. Schmidt was supported by the French Intensive Care Society (SRLF), the “Fonds de dotation Recherche en Santé Respiratoire, 2012,” the “Collège des Enseignants de Réanimation Médicale,” and the “Fonds d’Etude et de Recherche du Corps Médical des Hôpitaux de Paris.”

Dr. Dres has a conflict of interest with Pulsion Medical System (Feldkircher, Germany). Dr. Azoulay has conflicts of interest with Gilead (Forter City, California), Alexion (Zurich, Switzerland), Astellas (Levallois Perret, France), Pfizer (Paris, France), and Fisher & Payckle (Villebon-sur-Yvette, France). Dr. Demoule has conflicts of interest with Covidien (Dublin, Ireland), Maquet (Solna, Sweden), and Philips (Andover, Massachussets). The other authors declare no competing interests.