Evaluating the effectiveness of psychological care for intensive care unit patients at nutritional risk: A comparative study

Abstract

BACKGROUND

The intensive care unit (ICU) is a core hospital unit for critically ill patients. A high-intensity treatment environment, frequent invasive procedures, and isolation from family members often lead to severe psychological stress reactions in patients, including anxiety, depression, and posttraumatic stress disorder. Studies have reported that up to 50% of patients in the ICU experience varying degrees of psychological disorders, leading to reduced treatment compliance and exacerbated metabolic disorders through neuroendocrine pathways, thereby negatively affecting prognosis.

AIM

To investigate the influence of psychological nursing interventions on psychological status and all-cause mortality among patients admitted to the ICU.

METHODS

Data were obtained from 100 patients with nutritional risk in the ICU of the Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, admitted from June 2021 to June 2023. They were randomly divided into two groups (n = 50 each) based on nursing intervention: Control and study groups. At follow-up, the Zung Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS) were used. All-cause mortality and time to death were compared between the two groups. The relationship between psychological status and all-cause mortality was assessed using the Cox proportional hazards regression model.

RESULTS

There were no statistically significant differences in SAS and SDS scores between the two groups before the nursing intervention (P > 0.05). However, after the psychological intervention, the SAS and SDS scores of the study group were significantly lower than those of the control group (P < 0.05). The all-cause mortality rates in the study and control groups were 20% and 40%, respectively (P < 0.05), indicating that psychological nursing interventions can significantly reduce all-cause mortality and improve clinical outcomes. Cox proportional hazards regression analysis revealed that a good psychological state reduced all-cause mortality (P < 0.05). Nursing satisfaction in the study group was significantly higher than that in the control group (P < 0.05), indicating a high level of recognition of the psychological intervention.

CONCLUSION

Psychological nursing interventions can effectively reduce the incidence of anxiety and depression in ICU patients with nutritional risk, improve their psychological state, reduce all-cause mortality, and improve their prognoses.

Key Words: Psychological nursing intervention; Nutritional risk; Intensive care unit; Psychological status; All-cause mortality

Core Tip: The presence of varying degrees of psychological disorders in patients in the intensive care unit not only reduces treatment compliance but may also exacerbate metabolic disturbances through neuroendocrine pathways, thus negatively affecting prognosis. This study is the first to focus on intensive care unit patients at nutritional risk and to innovatively reveal the clinical value of psychological interventions to improve their psychological status, reduce all-cause mortality, and improve their prognosis.

INTRODUCTION

The intensive care unit (ICU) is a highly stressful environment in which critically ill patients are often experiencing life-threatening conditions and undergo invasive treatment and prolonged immobilization. Although advances in medical technology have significantly improved survival rates, the psychological toll on patients in the ICU, including anxiety, depression, and post-intensive care syndrome, remains a pressing concern. Emerging evidence indicates that psychological distress not only diminishes patient quality of life but also impedes physiological recovery, particularly among patients with concurrent nutritional risk. Nutritional risk, characterized by inadequate caloric intake, impaired metabolic function, or pre-existing malnutrition, exacerbates immune dysfunction, delays wound healing, and increases susceptibility to infections. These intertwined biological and psychological challenges underscore the need for integrated care models that address physical and mental health issues in ICU settings.

Nutritional risk is the risk of compromising the outcome of a disease or procedure owing to undernutrition, metabolic abnormalities, or increased demand[1]. For patients admitted to the ICU, physicians assess nutritional risk to determine its presence and severity. In the absence of contraindications, early nutritional supportive care is initiated for the patient, generally at 24-48 hours after resuscitation and initial treatment. ICU patients with nutritional risk often encounter physical and psychological burdens[2,3]. Previous studies have demonstrated that anxiety and depression are the most common psychological problems experienced by such patients[4]. In particular, patients who have failed previous treatments and undergo repeated treatments may experience psychological pressure that is difficult for healthy individuals to understand, and this may adversely affect treatment results[5]. In this study we investigated nutritional risk among patients in the ICU undergoing nutritional support treatment between June 2021 and June 2023. Our aim was to evaluate the influence of a psychological nursing intervention on ICU patients at nutritional risk after nutritional support, as this is beneficial for reducing all-cause mortality, further improving nursing measures, and improving clinical outcomes. Psychological interventions such as cognitive behavioral therapy, mindfulness-based stress reduction, and family-centered support have demonstrated promise for mitigating ICU-related psychological burdens. However, their efficacy in patients with nutritional risk remains unclear. Previous studies have predominantly focused on either nutritional optimization or psychological support in isolation, neglecting the potential synergistic effects of combining these approaches. This gap is critical, as malnutrition may amplify neuroendocrine stress responses, thereby diminishing the effectiveness of psychological therapies. Conversely, targeted psychological care can improve patient adherence to nutritional protocols, creating a bidirectional relationship that merits further investigation. The findings of this study have significant implications for ICU protocols. By clarifying the interplay between psychological well-being and nutritional health, the results of this study may inform the development of holistic patient-centered strategies to improve short-term survival and long-term functional outcomes in critically ill populations.

MATERIALS AND METHODS

General information

Participants in the present study included patients at nutritional risk who were admitted to the ICU and received nutritional supportive treatment at the Central Hospital of Enshi Tujia and Miao Autonomous Prefecture between June 2021 and June 2023. One hundred patients were preliminarily screened according to predefined inclusion and exclusion criteria. Clinical data were retrospectively analyzed, and patients were randomly divided into two groups according to the psychological nursing intervention, including control (n = 50) and study (n = 50). Patients ranged in age from 35 to 75 years (12-75 years, 12 obedient in the department), with a mean ± SD of 58.3 ± 7.5 years [59 male and 41 female; 20 mild-severe, 45 moderate-severe, and 35 severe; mean body mass index (BMI) of 23.85 ± 0.32 kg/m² (range, 23.01-25.42 kg/m²)]. General data, including age, severity, BMI, and sex between the two groups are presented in Table 1. The baseline characteristics of the control and study groups exhibited no significant differences (P > 0.05), indicating that this patient cohort could be used in this study. This study was reviewed and approved by the ethics committee of the Central Hospital of Enshi Tujia and Miao Autonomous Prefecture (Approval No. 20220142).

Table 1 Analysis and comparison of general data between two groups, mean ± SD.

Group	Number	Age (year)	Order of severity (n)			Body mass index (kg/m2)	Gender (male/female, n)
			Mild	Moderate	Severe
Control group	50	30.1 ± 2.1	16	23	11	23.43 ± 1.98	29/21
Study group	50	29.9 ± 3.1	14	22	14	23.59 ± 1.24	30/20
t/χ2		0.171	0.190	0.040	0.234	0.281	0.041
P value		0.680	0.663	0.840	0.597	0.597	0.839

The inclusion criteria were as follows: Clinical diagnosis with confirmed ICU nutritional risk and nutritional support[6], awareness and voluntary acceptance by the patient or family members; complete clinical data. The exclusion criteria were as follows: (1) Early stage of resuscitation, particularly when volume resuscitation was insufficient and hemodynamics had not yet stabilized; (2) Presence of severe metabolic disorders; (3) Severe hepatic dysfunction, hepatic encephalopathy, and severe azotemia; and (4) Difficulty in effectively implementing nutritional support.

Nursing methods

Control group: Patients maintained healthy habits (but were permitted to smoke), full rest, and a good mood. Real-time monitoring of vital signs (basal body temperature and blood pressure) was conducted. Vital signs monitoring: Real-time monitoring of heart rate and rhythm, blood pressure, respiratory rate, and blood oxygen saturation (i.e., oxygen saturation). Temperature management: Regular measurement of body temperature, physical cooling, or pharmacological intervention for patients with high fever, and rewarming for patients with low body temperatures. Hemodynamic monitoring: Invasive blood pressure monitoring using arterial catheters (such as radial artery catheterization) and central venous pressure assessment of volume status. Laboratory examinations: Regular arterial blood gas analysis, electrolytes, coagulation function, and others to adjust treatment plans in a timely manner. Airway management: Ensure the patency of the artificial airways (endotracheal intubation/tracheotomy), regular suctioning, and use of humidifiers to prevent sputum crusts. Mechanical ventilation support: Adjust ventilator parameters (such as tidal volume and positive end-expiratory pressure) according to medical orders and monitor airway pressure and blood gas results. Prevention of ventilator-associated pneumonia: Elevate the head of the bed by 30-45 degrees, provide daily oral care (with chlorhexidine solution), and replace regular ventilator circuits. Fluid balance management: Input and output volumes (urine output, drainage volume, and infusion volume) are used to maintain water and electrolyte balance. Prevention of deep vein thrombosis: Use of lower extremity compression devices (intermittent pneumatic compression) and low-molecular-weight heparin anticoagulation therapy (in the absence of contraindications). Timely and effective health guidance should not bias patient cognition of the disease, and patients should be informed of contraindications to the treatment process in detail[7].

Study group: Combination of routine nursing with psychological nursing intervention. First, by professional video introduction, pictures indicate patients’ intuitive ICU nutrition risk after the curative effect of nutritional support, cognitive intervention in patients, and receiving information regarding psychological factors are closely related to the quality of treatment effect, thus enabling patients to understand the current treatment and nursing plan and the need to pay attention to their treatment process[8,9]. Cognitive intervention can be conducted twice per week to ensure that patients receive timely and effective treatment and to alleviate the aggravation of anxiety and depression caused by improper cognition[10]. In psychological nursing, a clean and tidy room with a soft tube (light) line and gentle tone is used so that patients can maintain comfort, relieve tension, and remain open and responsive to their nursing care[11]. Nursing staff should be sincere, talk and communicate in depth with patients, earn the trust of patients, and understand the patient’s inner thoughts to accurately grasp the psychological change process in a timely manner to eliminate adverse factors, as psychological support helps patients to adjust their mentality and establish confidence in the treatment of the disease[12,13]. In addition to psychological nursing intervention for patients, patients’ families should also be actively involved and informed that companionship is beneficial for easing tension in patients[14].

Cox proportional hazards regression model assessment

Patients were divided into Q1-Q3 groups based on their mental state scores, and the relationship between mental status and all-cause mortality was assessed using Cox proportional hazards regression analysis.

Observation indicators and evaluation methods

Zung Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) scores, satisfaction with nursing care, all-cause mortality, incidence of complications, and physiological stress indicators were compared between the two groups.

SAS score: A higher score indicates more severe anxiety. A score < 50 indicated a patient with a stable mood and significant improvement in anxiety, while a score between 50 and 59 indicated minor anxiety, a score between 59 and 69 indicated moderately severe anxiety, and a score > 69 indicated severe anxiety[15,16].

SDS score: Symptoms were rated according to their frequency of occurrence on four scales (1, 2, 3, and 4), with total scores ranging from 20 to 80. A score < 50 is normal, 50-60 indicates mild depression, 61-70 indicates moderate depression, and ≥ 70 indicates severe depression.

Satisfaction with nursing: The nursing satisfaction questionnaire included five items, each scored at 20 points, where 0-60 indicates dissatisfaction, 60-85 indicates basic satisfaction, and 85-100 indicates satisfaction. Satisfaction = (total number of dissatisfied numbers)/total number[17].

Statistical analysis

Experimental data are expressed as mean ± SD. Between-group comparisons were performed using the independent t-test, and count data were assessed using the χ² test. Differences with P < 0.05 were considered statistically significant. The relationship between mental status and all-cause mortality was assessed using a Cox proportional hazards regression model.

RESULTS

Comparison of SAS and SDS scores between the 2 groups

Before nursing intervention, the SAS and SDS scores were not significantly different (P > 0.05), but they decreased after psychological nursing intervention. The SAS and SDS scores in the intervention group were lower than those in the control group, and the difference was statistically significant (P < 0.05; Table 2).

Table 2 Comparison of Self-Rating Anxiety Scale and Self-Rating Depression Scale scores between the two groups, mean ± SD.

Group	Anxious SAS		Depressed SDS
	Before the intervention	After the intervention	Before the intervention	After the intervention
Study group, n = 50	53.11 ± 5.28	47.28 ± 5.04	58.28 ± 7.99	47.79 ± 73.4
Control group, n = 50	53.12 ± 5.55	49.85 ± 5.37	57.63 ± 8.03	50.55 ± 7.23
t	0.000	7.306	0.198	4.471
P value	0.992	0.007	0.658	0.037

SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale.

Comparison of all-cause mortality between the 2 groups

Ten (20%) and 20 (40%) deaths occurred in the control and experimental groups, respectively. All-cause mortality was significantly different between the two groups (P < 0.5), suggesting that psychological nursing interventions can significantly reduce all-cause mortality and improve clinical outcomes.

Results of Cox proportional hazards regression model analysis of the effect of mental status on all-cause mortality

Uncorrected model 1 revealed that good psychological status in at-nutrition-risk ICU patients reduced all-cause mortality (P < 0.05). Model 2, adjusted for age, sex, and depression status, and model 3, adjusted for age, sex, BMI, and anxiety status, revealed that psychological status in at-nutrition-risk ICU patients was associated with all-cause mortality (P < 0.05). Model 6, adjusted for all of the aforementioned factors, revealed that the psychological status of the patients with nutrition risk in the ICU was related to all-cause mortality (P < 0.05), with model 6 exhibiting the highest concordance index (Table 3).

Table 3 Results of the Cox proportional hazards regression model analysis of mental status on all-cause mortality.

Model	HR	95%CI	Concordance index	P value
Model 1			0.62
Q1	1.00
Q2	0.63	0.42-0.93		< 0.05a
Q3	0.25	0.15-0.44		< 0.01b
Model 2			0.75
Q1	1.00
Q2	1.79	1.15-2.75		< 0.01b
Q3	1.15	0.67-2.15		0.58
Model 3			0.78
Q1	1.00
Q2	1.73	1.12-2.68		< 0.05a
Q3	0.79	0.32-0.94		0.621
Model 4			0.83
Q1	1.00
Q2	1.76	1.45-2.73		< 0.05a
Q3	1.57	1.05-2.24		< 0.05a

^aP < 0.05.

^bP < 0.01.

Model 1 for uncorrected; model 2 for age, sex, body mass index, and depression status; model 3 for age, sex, body mass index, and anxiety; and model 4 for all these factors. HR: Hazard ratio; CI: Confidence interval.

Comparison of nursing satisfaction between the 2 groups

Satisfaction of the intervention group with nursing was significantly higher than in the control group (P < 0.05), indicating a high recognition of the effects of the psychological intervention (Table 4).

Table 4 Comparison of the two groups, n (%).

Group	n	Discontent	Be basically satisfied	Satisfied	Degree of satisfaction
Study group	50	1 (2)	14 (28)	35 (70)	49 (98)
Control group	50	12 (24)	16 (32)	22 (44)	38 (76)
χ2					10.439
P value					0.001

Incidence of complications

The incidences of hospital-acquired pneumonia (12% vs 28%) and deep vein thrombosis (6% vs 18%) were significantly lower in the intervention group than they were in the control group (both P < 0.05; Table 5).

Table 5 Comparison of complication rates between two groups of patients, n (%).

Complication type	Study group (n = 50)	Control group (n = 50)	P value
HAP	6 (12)	14 (28)	0.036
DVT	3 (6)	9 (18)	0.047

HAP: Hospital-acquired pneumonia; DVT: Deep vein thrombosis.

Physiological stress indicators

After the intervention, mean heart rate in the study group was 84 ± 11 beats/minute vs 96 ± 14 beats/minute in the control group. Systolic blood pressure was 125 ± 15 mmHg in the study group vs 138 ± 18 mmHg in the control group. Both parameters were more stable than those in the control group (both P < 0.05; Table 6).

Table 6 Comparison of physiological stress indicators between two groups of patients, mean ± SD.

Physiological parameters	Study group (n = 50)	Control group (n = 50)	P value
Average heart rate (beats/minute)	84 ± 11	96 ± 14	0.021
Systolic blood pressure (mmHg)	125 ± 15	138 ± 18	0.016

DISCUSSION

The critical level of nutritional status, also referred to as “nutritional risk”, may manifest itself gradually over time due to insufficient food intake or may develop swiftly as a consequence of metabolic dysfunction induced by severe stress. In the first scenario in which the process unfolds at a slower pace, the body can adjust to the state of semi-starvation and use its nutrient reserves to sustain itself. However, when nutritional risk emerges in the context of patients experiencing severe stress, it can cause greater damage to their health[18,19]. Patients in the ICU are particularly vulnerable to acute malnutrition due to their critical condition. Providing sufficient nutritional support can prevent the onset of malnutrition, and in cases where patients are already well-nourished upon admission, adequate nutritional support may even enhance clinical outcomes[20]. Due to the poor prognosis of the disease and the additional burden of nutritional risks, the psychological status of patients in the ICU is often affected. Therefore, it is crucial to understand the psychological changes of patients in a timely and comprehensive manner and to take appropriate measures to improve their psychological status[21,22].

There was less difference in SAS and SDS scores in the study group before receiving psychological intervention (SAS 47.28 ± 5.04, SDS 47.79 ± 73) vs the control group (SAS 49.85 ± 5.37, SDS 50.55 ± 7.23) (P < 0.05). A follow-up comparison of all-cause mortality in both groups confirmed that all-cause mortality in the study group (20%) was significantly lower than that in the control group (40%). Assessment of nursing satisfaction revealed much higher satisfaction in the study group than in the control group (P < 0.05), indicating a high degree of recognition of the psychological interventions. Meanwhile, the psychological status of patients in the ICU who were at nutritional risk was associated with all-cause mortality (P < 0.05), and this is consistent with previous studies[4,23]. This study demonstrated significant improvements in both psychological and clinical outcomes following psychological nursing interventions in patients in the ICU with nutritional risk. Before the intervention, there were no significant differences in the SAS and SDS scores between the study and control groups (all P > 0.05). However, post-intervention, the study group exhibited markedly lower SAS and SDS scores than those of the control group (all P < 0.05), indicating a substantial reduction in anxiety and depression symptoms through targeted psychological care. The all-cause mortality rate in the study group [20% (10/50)] was significantly lower than that in the control group [40% (20/50)] (P < 0.05), highlighting the potential of psychological interventions to enhance survival in nutritionally vulnerable ICU populations. Cox proportional hazards model analyses consistently identified psychological status as an independent predictor of mortality. In the unadjusted model 1, better psychological status was associated with a reduced mortality risk (P < 0.05). This association persisted after sequential adjustments for age, sex, depression (model 2), BMI, and anxiety (model 3) and remained robust in the fully adjusted model 6 (P < 0.05). Model 6 that incorporated all the covariates achieved the highest predictive accuracy (concordance index), underscoring the critical role of mental health in modulating survival. Nursing satisfaction in the study group significantly surpassed that in the control group (P < 0.05), reflecting strong patient acceptance of integrated psychological care strategies.

Study limitations

Limitations of this study include the absence of an evaluation of psychotherapeutic and counseling interventions as potential protective factors. The 100 patients were from a single center, limiting generalizability. The follow-up period of the study was relatively short, and the long-term effects of the psychological interventions were not assessed. Additionally, the lack of blinding between assessors may have contributed to measurement bias. The absence of baseline medication records may also have affected mortality outcomes. In the future, large, multicenter studies could be designed to incorporate standardized assessment modules for psychological interventions, and long-term follow-up of participants, strict implementation of assessor blinding, and comprehensive collection of detailed clinical data at baseline and during follow-up could improve the representativeness of the findings.

CONCLUSION

In conclusion, this study revealed that psychological interventions to improve the psychological status and clinical outcomes of patients with nutritional risk in the ICU undergoing nutritional support therapy possess some utility in clinical practice. However, further research is needed to address these limitations and clarify the role of various psychological support measures in this patient population.