**Background:** Family caregivers of ICU patients frequently experience post-intensive care syndrome-family (PICS-F), including fatigue, anxiety, depression, posttraumatic stress symptoms, and complicated grief. Despite recommendations for family-centered care, structured models for individualized caregiver follow-up from ICU admission through post-discharge or bereavement are lacking. ICU nurses are well-positioned to provide such support but often lack resources and structured tools.
**Methods:** The model was developed using a participatory co-design approach in two phases. In the preparation phase, a stakeholder meeting was held with managers and experienced ICU nurses (n=4) for organizational anchoring. A literature search on PubMed (March 2019) using terms including 'intensive care unit,' 'caregivers,' 'family,' and 'follow-up' initially yielded 82 articles; after screening, 16 articles contributed concrete recommendations. Semi-structured interviews were conducted with former caregivers (n=8; median age 49 years, range 38-65; 3 male, 5 female; 3 bereaved) recruited via purposive sampling by ICU nurses. Interviews explored support received, needs, and preferences during and after the ICU stay. Transcripts were analyzed thematically using NVivo 12. In the development phase, a preliminary model was refined through 5 stakeholder workshops over 14 months with managers and ICU nurses (n=10). User testing was conducted with former caregivers (n=4) and experienced ICU nurses (n=11), who provided iterative feedback on the digital assessment tool content and wording, the supportive card text, and conversation guidelines. The study was approved by Oslo University Hospital's institutional review board (19/09470).
**Key Results:** The literature search identified caregivers' experiences as overwhelming and uncertain, with feelings of helplessness, fear, and being overburdened. Recommendations included 'get to know' conversations, information leaflets, screening for anxiety and depression, assigned nurses, flexible visiting hours, discharge conversations, follow-up conversations, and patient diaries. Caregiver interviews revealed three main themes: (1) Being present — caregivers wanted to be with the patient as much as possible, finding comfort in presence and worrying about the patient feeling alone; (2) Receiving adequate information — timely, clear, and consistent information was described as 'something to hold on to' in uncertainty, and inadequate information caused additional stress, particularly during transitions; (3) Emotional care — respect, caring words, practical support (e.g., offering water, facilitating rest), and the ability to talk about difficult feelings were highly valued. Caregivers reported exhaustion, guilt, isolation after returning home, and varied access to professional support. The final model comprises four steps: Step 1 — within the first few days of ICU admission, caregivers complete a digital assessment tool on a tablet to map their needs and challenges, followed by a conversation with an ICU nurse; Step 2 — at ICU discharge, caregivers receive a supportive card with information acknowledging their situation and encouraging help-seeking; Step 3 — 1-2 days after ICU discharge, caregivers are offered a discharge phone conversation focusing on how they are doing and any questions or concerns (not offered if patient died or moved to a unit with equivalent follow-up); Step 4 — within 3 months after ICU stay, caregivers (bereaved or not) are offered an individual follow-up conversation, either in person or by phone, to discuss memories from the ICU, clarify misunderstandings, reflect on the experience, and assess need for additional support.
**Clinical Implications:** The Caregiver Pathway provides a structured, evidence-based, and user-informed model that can help ICU nurses systematically assess and address caregivers' individual needs, potentially preventing or mitigating PICS-F. By facilitating communication about caregiver involvement, information needs, and emotional well-being, the model promotes family-centered care. The digital assessment tool may help caregivers articulate needs they might not otherwise express, and the structured follow-up ensures that all caregivers receive attention regardless of their health literacy or ability to navigate the healthcare system. The model was designed to be feasible within a busy ICU environment, with stakeholder emphasis on ease of use and nurse motivation. Before implementation, organizational support and resources from ICU management are essential to avoid overburdening nurses. The model may be transferable to other ICUs and healthcare settings, but requires tailoring to local contexts. Future research should test the model in a randomized controlled trial to evaluate its feasibility and impact on caregiver outcomes.