Our survey reveals that the design and organization of many French ICUs remain poorly adapted to promoting patient comfort. Caregivers responding to our survey consider that anxiety, sleep disturbance, feelings of restraint, noise, and pain are the most significant sources of patient discomfort. However, caregivers rarely take action to alleviate them.
Patients have identified anxiety, pain, thirst, and sleep disturbance as major sources of discomfort and stress during their ICU stay [1–4]. Our results indicate that caregiver’s identification of sources of discomfort at least partly overlaps with patient experience, with caregivers viewing pain and anxiety as the main sources of patient discomfort. Pain is a major source of discomfort, with half of the patients surveyed in previous studies reporting that they experienced pain during their ICU stay [1, 2]. Because pain has been linked to delirium and PTSD [10, 11], rapid, patient-tailored pain relief is strongly recommended. However, although almost all those responding to our survey routinely evaluated and treated pain, less than half the responding ICUs had a nurse-driven analgesia protocol. This type of protocol was nevertheless considered to be very useful or essential by almost all respondents.
According to our results, anxiety is considered on a daily basis by a large majority of caregivers. Nevertheless, only a small number of ICUs have a full-time psychologist, apart from pediatric ICUs, where their presence has been recognized as necessary for many years as part of support for sick children, parents, and staff. Additionally, some factors contributing to anxiety (such as lack of space and time references, sleep disturbance, lack of information, or missing loved ones) are insufficiently addressed. For example, in one-third of ICUs, patients did not have access to a clock, and only very few ICUs kept them informed of the date. Anxiety can lead to sleep disturbance, which is frequent in the hospital setting  and is reported as stressful by two out of three patients . Despite this, only half of our respondents routinely evaluated patient’s sleep. Causes of sleep disturbance were frequently noted, such as multiple-occupancy rooms, no means to adjust light intensity, and limited efforts by many caregivers to reduce noise. Patient anxiety also can be promoted by a lack of information and an inability to communicate [1, 13]. To help overcome this inability, nonverbal means of communication are recommended [14–16]. However, our results reveal that these methods are not used in one-third of our respondents’ ICUs. Finally, restricting visits from loved ones is also a source of patient anxiety and PTSD [10, 13, 17]. The French consensus conference  concluded that next of kin should be allowed to visit without time restrictions, in line with the needs of care and patients’ wishes; children also should be admitted as part of supervised access . The results presented here reveal that one in two adult ICUs still have restrictive visiting policies. However, a 24-h visiting policy was advocated by a large majority of respondents. Interestingly, physicians were slightly more reluctant to adopt a liberal policy than paramedics even though a 24-h visiting policy was demonstrated to be favorably perceived by caregivers in units where it was tested . Although it is not currently recommended, our results showed that a majority of ICUs require visitors to wear a gown. This could contribute to preventing visitors from feeling comfortable while visiting patients. A gown was required in as many ICUs with a 24-h visiting policy as ICUs with restricted visiting. This suggests that this practice is not directly linked to an overall policy of facilitating family’s access to ICUs.
In ICUs, noise levels have been extensively demonstrated to be above the World Health Organization recommendations [20, 21]. In our survey, noise was considered as one of the main sources of patient discomfort. However, although a memory of irritating noises has been shown to be associated with the occurrence of PTSD  most patient-based studies did not rate noise as very stressful [1, 2]. This possible overestimation of noise as a source of discomfort by caregivers could be because they consider noise to be the main cause of sleep disturbance whereas, in fact, anxiety and pain may be more to blame. It also may indicate that the noisy environment of many ICUs is more readily perceived by caregivers. Although noise levels could be readily modified by applying some simple strategies , few of those responding to our survey used methods to reduce noise or to assess how noise affects patient comfort.
The body often is exposed during care , and both patients and families indicate that privacy and confidentiality should be respected during care [25, 26]. An adapted single-occupancy room favors privacy and confidentiality, allows families to participate in care and encourages closer relations with loved ones during an ICU stay [25, 27]. In the present survey, one-third of ICUs did not have only single-occupancy rooms. We also found that family participation in care remains very rare in adult ICUs. A recent single-centre survey found that perception of participation in simple care, such as moistening of the oral cavity or hydrating the lips, was very favorably perceived by both caregivers and family .
The present study has some limitations. It is based on a survey of opinions and declared practices, rather than a practice audit. ICUs or caregivers were not preselected, and the proportion of ICUs from teaching hospitals represented is higher than the national average. Because of this, our results may not be perfectly representative of ICU policies and opinions in French-speaking areas. However, there was no significant difference in characteristics of caregivers from teaching and nonteaching hospitals. The response rate also was much higher for nurses than for physicians, which limits the validity of comparisons between these two groups. Moreover, this difference suggests that efforts must be made to motivate participation by doctors interested in the field of quality of care.