Preferred content and usefulness of a photodiary as described by ICU-patients--a mixed method analysis

Family's preferences for and experiences of writing practices in adult intensive care and its use in early bereavement: A descriptive qualitative study

BACKGROUND

Family partaking in writing practices, such as writing intensive care unit (ICU) patient diaries, personal diaries/journaling, social media, or instant messaging services, during ICU admission may allow the family to unintentionally participate in a form of expressive writing. These writing practices could provide structure for the family authors to explore emotions and manage significant life events, including death of a loved one. Limited studies have explored the family's postmortem experiences and perceived value of writing practices maintained during an ICU admission.

OBJECTIVES

The objective of this study was to explore the family member's preferences for and experiences of writing practices in the adult ICU and its use in early bereavement.

METHODS

descriptive qualitative design using inductive reflexive thematic analysis from a purposeful, convenience sample of 16 bereaved participants from a tertiary referral, adult ICU in Australia who discussed their experiences of and preferences in writing practices. Reporting adheres to the consolidated criteria for reporting qualitative research checklist.

FINDINGS

Six participants maintained writing practices during the ICU admission and 10 did not. Three themes were generated from the data: the decision to maintain writing practices was shaped by past behaviours and perceived utility; moments captured were influenced by the loved ones' clinical status and their ability to access the writing medium; and writing practices have limited utility as a memory making object in early bereavement.

CONCLUSIONS

Based on the generated findings, participants who did not maintain writing practices did not later regret this decision during early bereavement. Participants who did maintain writing practices predominately used a personal diary/journal that they carried with them. As the loved one approached death, the written entries became shorter, then ceased. Most of the written entries were not read during early bereavement, suggesting the writing practices' psychological value might have been predominately gained at the time of writing, rather than during early bereavement.

Photographs in burn patient diaries: A qualitative study of patients' and nurses' experiences

OBJECTIVE

To explore burn patients' and burn intensive care nurses' experiences of the photos in patient diaries.

DESIGN

A qualitative inductive study using thematic analysis was performed. We conducted individual interviews with six former burn patients (age range 20-77 years; four women), and two focus groups with 11 burn intensive care nurses (age range 38-61 years; all women). Data from patients and nurses were analysed together, and the findings reported according to the consolidated criteria for reporting qualitative research (COREQ).

SETTING

A Norwegian burn centre where the writing of diaries including text and photos has been practiced for approximately two decades.

FINDINGS

Three main themes were derived from the combined analysis of the two data sets: hesitating when facing photos; visualising others care; and visualising the trajectory from burn trauma to recovery. Although the patients worried beforehand about what they would see in the photos and the nurses feared to select frightening photos, the photos were welcome, and several patients said they would have liked even more. The photos filled in gaps of memory, told more than words, and did not lie. Photos of family, friends or staff demonstrated shared actions that supported memories and recovery.

CONCLUSION

Both the burn patients and the burn intensive care nurses considered photos to be an essential part of the diary that gave context and provided a factual presentation of the patients' pathway of treatment, care and recovery.

IMPLICATION FOR CLINICAL PRACTICE

Tailored information about photo content should be offered to patients before a diary is handed over to them. Nurses should attempt to include photos covering the patients' entire stay at the burn centre, as well as photos of family, friends and staff. Individual nurses should be supported in their practical selection of photos for the diary.

Thematic analysis of intensive care unit diaries kept by staff: insights for caring

OBJECTIVE

To explore recurrent themes in diaries kept by intensive care unit (ICU) staff during the coronavirus disease 2019 (COVID-19) pandemic.

DESIGN

Qualitative study.

SETTING

Two ICUs in a tertiary level hospital (Milan, Italy) from January to December 2021.

METHODS

ICU staff members wrote a digital diary while caring for adult patients hospitalized in the intensive care unit for >48 hours. A thematic analysis was performed.

FINDINGS

Diary entries described what happened and expressed emotions. Thematic analysis of 518 entries gleaned from 48 diaries identified four themes (plus ten subthemes): Presenting (Places and people; Diary project), Intensive Care Unit Stay (Clinical events; What the patient does; Patient support), Outside the Hospital (Family and topical events; The weather), Feelings and Thoughts (Encouragement and wishes; Farewell; Considerations).

CONCLUSION

The themes were similar to published findings. They offer insight into care in an intensive care unit during a pandemic, with scarce resources and no family visitors permitted, reflecting on the patient as a person and on daily care. The staff wrote farewell entries to dying patients even though no one would read them.

IMPLICATIONS FOR CLINICAL PRACTICE

The implementation of digital diaries kept by intensive care unit staff is feasible even during the COVID-19 pandemic. Diaries kept by staff can provide a tool to humanize critical care. Staff can improve their work by reflecting on diary records.

The Use and Impact of Diaries in PICUs and Neonatal ICUs: A Scoping Review

OBJECTIVE

Several studies have investigated the impact of diaries in adult ICUs, which have been used as a tool to support recall and reduce post-traumatic stress disorder in patients and their families. We conducted a scoping review to determine the definition of ICU diaries, and the extent, range, and nature of research conducted on NICU and PICU diaries, describe their use and impact, as well as identify gaps in knowledge and areas for future research.

DATA SOURCES

The following databases were searched from inception to March 2022: Cumulated Index to Nursing and Allied Health Literature, Cochrane Library, Embase, PubMed, and American Psychological Association PsycINFO. Searches were also conducted in the following gray literature databases: Google Scholar, University of South Australia, and WorldCat.

STUDY SELECTION

All studies that discussed the use and impact of diaries or journals involving patients (<18 yr old) in PICUs and NICUs and/or their family members were included.

DATA SYNTHESIS

Sixteen studies were identified. Most studies defined diaries as daily entries written by nurses and/or family members regarding the patient's condition during their ICU admission. The majority reported that diaries were beneficial to children and their families as they helped to fill in memory gaps, provided a means to express their feelings, and served as effective health communication tools. Several gaps were identified: extent of the use of diaries as a means of communication, the significance of diaries as a coping mechanism for bereaved parents, and the impact of PICU diaries on the children, their families, and healthcare professionals.

CONCLUSIONS

There is a paucity of data on the use of NICU and PICU diaries. Nonetheless, the limited data revealed that NICU and PICU diaries were beneficial to children and their families. Our review demonstrated a heterogeneity in the terminology, content, use of photos, and the author/s of the NICU and PICU diaries. Further research is needed to investigate the impact of the use of NICU and PICU diaries on patient-reported outcomes.

On photovoice-Applications and reflections to an intensive care context

BACKGROUND

In this paper, we share our experiences of using 'photovoice' methodology as a way to generate data in intensive care units concerning the place and space of care. We have adapted and modified 'photovoice' in researching people's lived experiences of ICU. Researching lived experiences in an intensive care context is challenging because of the complex nature of critical care.

AIM

This study aims to explore and discuss photovoice methodolgy in ICU as a data collection method.

MATERIALS AND METHODS

Photos and interviews collected from patients, loved ones and staff collected in a previous research proejct.

RESULTS

Although there are challenges in using cameras and photographing the environment in the ICU, due to ethics and the voiceless patients therein, many advantages are presented to the researchers in capturing the meaning of lived experiences of various phenomena in the lifeworld in general and in the meaning of place and space. This paper offers applications and reflection over ontological, epistemological and methodological concerns and also offers a detailed approach on how to employ photovoice for successful and rich data generation.

DISCUSSION

developing and adapting scientific methods and methodologies contributes to knowledge development in caring science and is therefore an important subject of matter.

CONCLUSIONS

Photovoice also presents a powerful tool in disseminating the findings as it opens up the closed world of ICU to the public and increases people's understanding of the significance of place and space of caring practice.

Use of Intensive Care Unit Diary as an Integrated Tool in an Italian General Intensive Care Unit: A Mixed-Methods Pilot Study

PURPOSE

The aim of this study was to investigate the implementation of an intensive care unit (ICU) diary in an Italian general ICU.

METHODS

A mixed-methods pilot study was performed, enrolling all patients who received an ICU diary in an Italian ICU during the study period.

RESULTS

Study results are presented in 2 sections: (1) diary evaluation and content themes and (2) follow-up program results. Sixty-six patients were assessed for eligibility. Diary administration was possible in 31 patients (47%). The overall diary entries, in 31 analyzed diaries, were 1331, with a median of 25 entries (interquartile range, 16-57 entries) for each diary. Participants' relatives and friends wrote a median of 1.2 (0.3-1.6), and nurses wrote 1.1 (0.8-1.2). Other ICU staff wrote a total of 24 entries (2%). Follow-up results revealed low incidence of delirium detected in only 1 patient at the 7-day visit (3%). The median value of PTSS-10 (Post Traumatic Stress Symptoms) score was 12 (3.5-12) at the 7-day visit, 6 (1.5-12) at 3 months' telephone interview, and 12 (1.5-17) at 6 months' visit.

CONCLUSIONS

To our knowledge, this is the first Italian report about the introduction of an ICU diary. The diaries were easily implemented in our clinical practice as a "low-cost" initiative. In our study, nurses and participants' relatives and friends wrote a similar number of entries in each analyzed diary. This project could be effective in reducing survivors' delirium and post-traumatic stress disorder and in implementing mutual understanding between clinical staff and relatives during ICU stay.

Exploring Patients' Perceptions on ICU Diaries: A Systematic Review and Qualitative Data Synthesis

OBJECTIVES

This study aims to summarize the current qualitative evidence on patients' experiences of reading the ICU diaries.

DATA SOURCES

We searched the online databases PubMed, Ovid, EMBASE, and EBSCO host from inception to July 2020.

STUDY SELECTION

All studies that presented any qualitative findings regarding patients' experiences of reading an ICU diary were included.

DATA EXTRACTION

Study design, location, publication year, data collection method, and mode, all qualitative themes identified and reported, and participant quotations, when appropriate. We also extracted data regarding the diary structure, when available. A thematic synthesis approach was used to analyze and synthesize qualitative data.

DATA SYNTHESIS

Seventeen studies were analyzed. Most patients reported positive experiences with the ICU diary, such as understanding what they survived during critical illness, better understanding the process of recovery, gaining coherence of nightmares and delusional memories, realizing the importance of the presence of family and loved ones during ICU stay, and humanizing healthcare professionals that helped them survive critical illness. Patients also reported which components of the diary were important for their recovery, such as the presence of photographs and reading the diary with a healthcare professional, allowing the improvement of the concept of the ICU diary.

CONCLUSION

This qualitative synthesis shows that patients recommend having an ICU diary, enlightening benefits such as better coping with the slow recovery from critical illness, strengthening family ties, and humanizing the ICU staff. It also identifies characteristics of the diary valued by the patients, in order to standardize the ICU diary according to their perspectives, and allowing future comparability between randomized controlled trials.

Intensive Care Unit Patient Diaries: A Review Evaluating Implementation and Feasibility

Post-intensive care syndrome is a detrimental cluster of symptoms that can have a negative impact on life after discharge from the intensive care unit (ICU). The use of patient diaries while hospitalized in the ICU has been reported to help survivors and families create memories and fill in gaps from their hospitalization. A review of the literature revealed that patient selection, diary content, family involvement, and staff perceptions are essential to the implementation of a diary program. Understanding the importance and impact diaries can have on survivors increases compliance and sustainability of this program.

The impact of intensive care unit diaries on patients' and relatives' outcomes: a systematic review and meta-analysis

BACKGROUND

Memory gaps in intensive care unit (ICU) survivors are associated with psychiatric disorders. The ICU diaries improve the patient's factual memory of the ICU, but it is not clear if they reduce the incidence of psychiatric disorders in patients and relatives after hospital discharge. The aim of this study is to evaluate the literature on the effect of ICU diaries for patients admitted in ICU and their relatives.

METHODS

Two authors independently searched the online databases PubMed, OVID, Embase, EBSCO host, and PsycINFO from inception to July 2019. Studies were included if the intervention group (ICU diary) was compared with a group with no diaries and the sample was comprised patients ≥ 18 years old admitted in the ICU for more than 24 h and their relatives. Randomized clinical trials, observational studies, letter with original data, and abstracts were included, irrespective of the language. The search was not limited by any specific outcome. Review articles, commentaries, editorials, and studies without a control group were excluded. Structured tools were used to assess the methodological quality ("Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I)" for cohort studies and the "Cochrane Risk of Bias tool" for included RCTs and before/after studies). A random-effects model was employed considering the anticipated variability between the studies.

RESULTS

Seven hundred eighty-five titles were identified for screening. Two additional studies were selected after a reference search, and after a full-text review, a total of 12 studies were included. When pooling the results, ICU diary was associated with lower risk of depression (RR 0.41, 95% CI 0.23-0.75) and better quality of life (10.3 points higher in SF-36 general health score, 95% CI 0.79-19.8), without a decrease in anxiety or post-traumatic stress disorder (PTSD). For the relatives receiving an ICU diary, there was no difference in the incidence of PTSD, anxiety, or depression.

CONCLUSION AND RELEVANCE

This systematic review and meta-analysis supports the use of ICU diaries to reduce the risk of depression and preserve the quality of life of patients after ICU admission. ICU diaries do not seem to have any beneficial effect on the relatives of the patients.

TRIAL REGISTRATION

PROSPERO, CRD42019136639.

Preventing Posttraumatic Stress in ICU Survivors: A Single-Center Pilot Randomized Controlled Trial of ICU Diaries and Psychoeducation

OBJECTIVES

Critical illness can have a significant psychological impact on patients and their families. To inform the design of a larger trial, we assessed feasibility of ICU diaries and psychoeducation to prevent posttraumatic stress disorder, depression, and anxiety following ICU stays.

DESIGN

Four-arm pilot randomized controlled trial.

SETTING

A 10-bed tertiary ICU in Winnipeg, MB, Canada.

PATIENTS

Critically ill patients greater than 17 years old with predicted ICU stays greater than 72 hours and mechanical ventilation duration greater than 24 hours.

INTERVENTIONS

Patients were randomized to usual care, ICU diary, psychoeducation, or both ICU diary and psychoeducation.

MEASUREMENTS AND MAIN RESULTS

Our primary objective was to determine feasibility measured by enrollment/mo. Secondary outcomes included acceptability of the ICU diary intervention and psychological distress, including patients' memories 1 week post ICU using the ICU Memory Tool, posttraumatic stress disorder (Impact of Events Scale-Revised), depression, and anxiety symptoms (Hospital Anxiety and Depression Scale) 30 and 90 days post ICU. Over 3.5 years, we enrolled 58 patients, an average of 1.9 participants/mo. Families and healthcare providers wrote a mean of 3.2 diary entries/d (SD, 2.9) and indicated positive attitudes and low perceived burden toward ICU diary participation. A majority of patients reported distressing memories of their ICU stay. Those who received the diary intervention had significantly lower median Hospital Anxiety and Depression Scale anxiety (3.0 [interquartile range, 2-6.25] vs 8.0 [interquartile range, 7-10]; p = 0.01) and depression (3.0 [interquartile range, 1.75-5.25] vs 5.0 [interquartile range, 4-9]; p = 0.04) symptom scores at 90 days than patients who did not receive a diary.

CONCLUSIONS

ICU diaries are a feasible intervention in a tertiary Canadian ICU context. Preliminary evidence supports the efficacy of ICU diaries to reduce psychological morbidity following discharge.

Patients' perceptions of an intensive care unit diary written by relatives: A hermeneutic phenomenological study

OBJECTIVE

To explore patients' perceptions of an intensive care unit diary written by relatives including pictures added by staff.

DESIGN

Ten patients were interviewed 3-6 and 8-16 months after discharge from the intensive care unit. Most patients were interviewed with a relative present. Interviews were analysed using Ricoeur's theory of interpretation.

SETTING

Interviews took place in participants' homes.

FINDINGS

Patients found the diary written by relatives with photos taken by staff to be valuable providing information that helped them understand their time in the intensive care unit. The diary text gave patients insight into relatives' experiences and suffering. Patients were touched by the love and care conveyed in the diary, however, the diaries could overwhelm the patients when they were confronted with the grief and agony endured by their relatives.

CONCLUSION

Although diaries kept by relatives confront patients with consequences beyond their own suffering, they are informative and promote understanding of what patient and family experienced during critical illness. The diaries expressed how much the relatives cared for the patient thus paving the way for mutual support and understanding. Diaries authored by relatives represent a new element to ICU diaries that have evolved from a nursing intervention toward family participation.

Real and illusory perceptions of patients in induced coma

OBJECTIVE

To identify, in the scientific literature, real and illusory perceptions of adult patients in induced coma.

METHODS

This is an integrative review of 15 primary studies from the Medline, Web of Science, LILACS, CINAHL and SCOPUS databases.

RESULTS

The main memories reported after induced coma were thirst, cold, and pain. In some studies, patients reported they were unable to tell whether they were awake or dreaming, whether it was real or unreal. Satisfactory memories were reported by patients related to the care received and the use of bedside journals.

CONCLUSION

Evidence showed a number of studies aiming to identify delirium, but without a focus on analyzing real or illusory perceptions of patients after induced coma. Thus, this integrative review identified scientific evidence of memories related to perceptions of sedated patients in the intensive care unit.

Assessment of patient satisfaction and preferences with an intensive care diary

Objectives

To evaluate the satisfaction of patients admitted to the intensive care unit using a diary and analyze possible points for improving this instrument.

Methods

This was an observational, retrospective study, conducted between March 2014 and July 2017, in a multidisciplinary intensive care unit of a district hospital. The diary was implemented in patients sedated for 3 or more days. Three months after discharge, their satisfaction was assessed using a questionnaire. A patient who agreed with the 5 statements assessing the diary's help in clarifying the intensive care unit stay, in filling memory gaps, in recovery, in reassurance, and in the recommendation of this intervention was defined as satisfied.

Results

A total of 110 patients were included, of whom 55 answered the questionnaire. Of these, 36 (65.5%) were classified as satisfied. Each item had a positive response in more than 74% of cases. A total of 60% of the participants suggested increasing the number of photographs. No significant differences were found in the subgroup analysis (age, sex, duration of sedation and ventilation, length of diary keeping, severity on admission, or delirium, depression, or anxiety in the intensive care unit).

Conclusions

Most patients were satisfied with the diary but suggested an increase in the number of photographs.

The effect of family-authored diaries on posttraumatic stress disorder in intensive care unit patients and their relatives: A randomised controlled trial (DRIP-study)

BACKGROUND

Critical illness and mechanical ventilation may cause patients and their relatives to experience symptoms of posttraumatic stress, anxiety, and depression due to fragmentation of memories of their intensive care unit (ICU) stay. Intensive care diaries authored by nurses may help patients and relatives process the experience and reduce psychological problems after hospital discharge; however, as patients particularly appreciate diary entries made by their relatives, involving relatives in authoring the diary could prove beneficial.

OBJECTIVES

The objective of this study was to explore the effect of a diary authored by a close relative for a critically ill patient.

METHODS

The study was a multicenter, block-randomised, single-blinded, controlled trial conducted at four medical-surgical ICUs at two university hospitals and two regional hospitals. Eligible for the study were patients ≥18 years of age, undergoing mechanical ventilation for ≥24 h, staying in the ICU ≥48 h, with a close relative ≥18 years of age. A total of 116 relatives and 75 patients consented to participate. Outcome measures were scores of posttraumatic stress symptoms, anxiety, depression, and health-related quality of life three months after ICU discharge.

RESULTS

Relatives had 26.3% lower scores of posttraumatic stress in the diary group than in the control group (95% confidence interval: 4.8-% to 52.2%). Patients had 11.2% lower scores of posttraumatic stress symptoms in the diary group (95% confidence interval: -15.7% to 46.8%). There were no differences between groups in depression, anxiety, or health-related quality of life.

CONCLUSION

A diary written by relatives for the ICU patient reduced the risk of posttraumatic stress symptoms in relatives. The diary had no effect on depression, anxiety, or health-related life quality. However, as the diary was well received by relatives and proved safe, the diary may be offered to relatives of critically ill patients during their stay in the ICU.

Intervention fidelity in postintensive care follow-up consultations at ten sites in the RAPIT-trial: A mixed-methods evaluation

AIM

The aim of the study was to evaluate intervention fidelity of nurses' delivery of the RAPIT recovery program for postintensive care patients.

BACKGROUND

Interventions addressing patient problems after intensive care lack description of the process of delivery and the evidence of their effectiveness. This is needed to understand how these interventions work.

DESIGN

Multistage intervention framework in a mixed-methods design. Intervention fidelity strategies were assessed for intervention design, training, delivery, receipt, and enactment with quantitative and qualitative methods inspired by the Medical Research Council and the National Institutes of Health Fidelity Framework.

METHODS

Data collection was embedded in a multicenter randomized controlled trial to explore intervention fidelity of a recovery program (December 2012-February 2017). Ten Danish intensive care units participated in the RAPIT-trial including 386 patients and 27 nurses. Quantitative data covered training and delivery. Qualitative data explored design, quality of delivery, receipt, and enactment seen from nurses' and patients' perspectives. Data were analysed statistically and by systematic deductive-inductive thematic analysis.

FINDINGS

A framework for participatory enactment of a complex intervention was developed and demonstrated delivery with high consistent fidelity across sites. Low delivery doses and variations were related to the program, patient, provider nurses and context.

CONCLUSION

Our study provides insight into the process of intervention fidelity of a nurse-led postintensive care recovery program and potentially enables professionals to understand key factors in cross-site implementation. Although we demonstrate consistent delivery and variations suggest that some patients may benefit more than others.

Feasibility and Perceptions of PICU Diaries

OBJECTIVES

To determine the feasibility of implementing an ICU diary in the pediatric critical care setting and to understand the perceptions held by family members who receive the diaries after PICU discharge.

DESIGN

Observational pilot study.

SETTING

PICU in a tertiary academic hospital in the United States.

PARTICIPANTS

Critically ill pediatric patients admitted to the PICU and their families.

INTERVENTIONS

The addition of a PICU diary to a patient's routine care.

MEASUREMENTS AND MAIN RESULTS

Twenty families of critically ill children admitted to the PICU were enrolled in the PICU diary pilot study between May 2017 and March 2018. Patients who had an anticipated length of stay of at least 3 days and whose families were English-speaking were included. The median age of patients was 6 years, ranging from newborns to 18 years old, and the median length of stay was 11.5 days (interquartile range, 8.5-41 d). A total of 453 diary entries were written in 19 diaries over 433 PICU days, the majority of which were composed by bedsides nurses (63%). Follow-up surveys sent to parents 2 weeks after PICU discharge revealed that of the parents who had contributed to the diary, most enjoyed doing so (7/8). Nine of 12 parents had reviewed the diary at least once since discharge, and all parent respondents found the diary to be a beneficial aspect of their experience after PICU discharge.

CONCLUSIONS

The use of ICU diaries in the PICU setting is feasible and perceived as beneficial by families of critically ill children. Future studies are needed to better understand if PICU diaries may objectively improve psychologic outcomes of patients and family members after PICU admission.

The effect of diaries written by relatives for intensive care patients on posttraumatic stress (DRIP study): protocol for a randomized controlled trial and mixed methods study

Background

Critically ill patients and their relatives have complex needs for support during their stay in the intensive care unit (ICU) and the post-ICU rehabilitation period. Diaries written by nurses have proven beneficial for patients and relatives, preventing post-traumatic stress, anxiety and depression and helping patients and families find meaning. Actively involving relatives in writing a diary for critically ill patients is a new approach to helping relatives and patients cope; however, research is limited.The aim of this study is to test the hypothesis that a diary written by a close relative of a critically ill patient will reduce the risk of developing symptoms of post-traumatic stress disorder (PTSD) in the patient and relatives at 3 months post-ICU. Furthermore, the aim is to explore the perceptions and use of the diary and describe the diary content and structure.

Method

The intervention consists of a hard-cover notebook that will be given to a close relative to write a diary for the critically ill patient while in the ICU. Guidance will be offered by ICU nurses on how to author the diary. The effect of the intervention will be tested in a two-arm, single-blind, randomized controlled trial, which aims to include 100 patient/relative pairs in each group. The primary outcome studied is symptoms of post-traumatic stress (PTSS-14). Secondary outcomes are scores on anxiety and depression (HADS) and the Medical Outcomes Study Questionnaire Short Form 36 (SF-36). The narrative structure and content of the diary as well as its use will be explored in two qualitative studies.

Discussion

The results of this study will inform ICU nurses about the effects, strengths and limitations of prompting relatives to author a diary for the patient. This will allow the diary intervention to be tailored to the individual needs of patients and relatives.

Trial registration

NCT02357680. Registered September 3, 2015.

The provision of nurse-led follow-up at Norwegian intensive care units

AIMS AND OBJECTIVES

To describe the prevalence, content and administration of intensive care unit diaries and follow-up practices offered to patients and their families in Norway.

BACKGROUND

Intensive care treatment has been associated with risks for new or increased health impairments affecting both patients and their families. These impairments have the potential of continuing beyond the acute phase of treatment. In parallel, preventive actions have gradually become an integrated part of critical care nursing, and in Norway, national recommendations for the use of intensive care unit diaries have been established.

DESIGN AND METHODS

A survey was conducted in Norwegian intensive care units offering care for adult patients, using a questionnaire asking about the frequency, administration and content of the follow-up offered to patients, their relatives, as well as bereaved family members.

RESULTS

Thirty-nine of 66 (59.1%) invited intensive care units answered the questionnaire. The majority (n = 33, 84.6%) of the responding units had follow-up routines. The provision of diaries was the most frequent follow-up activity (n = 24, 61.5%), and consultations postdischarge formed an integrated part of the diary practice. Consultations with bereaved were conducted in 21 (53.8%) of the intensive care units. About one quarter of the responding intensive care units had positions for follow-up nursing staff.

CONCLUSION

Nurse-led follow-up after critical care was a common activity in Norwegian intensive care units, comprising diaries and consultations offered to patients and family members. The follow-up was mainly driven by bottom-up processes conducted by dedicated nurses motivated by the patients' and their families' situation and feedback.

RELEVANCE TO CLINICAL PRACTICE

Adherence to recommendations, as well as the availability of defined positions for aftercare nurses or teams, may improve the implementation of follow-up practices and reduce suffering after discharge from Norwegian intensive care units.

The meaning of personal diaries to children and families in the paediatric intensive care unit: A qualitative study

OBJECTIVE

To explore children's' and families' experiences of using intensive care diaries after discharge and the role of diaries in the process of recovering from a stay in the paediatric intensive care unit.

DESIGN AND SETTING

Qualitative, exploratory design. Data collection consisted of semi-structured interviews with five children and their families, conducted four to six months after discharge from the intensive care unit. Inclusion criteria were children and their families, with a stay for more than three days who had a diary written for them. Data were analysed using thematic analysis FINDINGS: Three main themes emerged: (i) value to the entire family, (ii) creating memories, (iii) the importance of pictures.

CONCLUSION

Diaries were used after discharge as a support for both children and families and played a role in making the paediatric intensive care experience meaningful by providing explanations and coherence. The findings suggest that a diary can serve as a catalyst for the coping process of the family unit. Findings also confirm how the children's memories are characterised by a sense of unreality. The diary could thus help fill in some of the missing picture to support the children in understanding their story.

Towards a new orientation: a qualitative longitudinal study of an intensive care recovery programme

AIMS AND OBJECTIVES

To describe the patient experience of ICU recovery from a longitudinal perspective by analysing follow-up consultations at three time-points.

BACKGROUND

After a stay in the intensive care unit, patients risk physical and psychological problems during recovery. Follow-up after intensive care has emerged to aid psychological recovery, and improve health-related quality of life. More insight is needed into the mechanisms of intensive care recovery.

DESIGN

A descriptive multicenter longitudinal qualitative design.

METHODS

A subsample of 36 consultations with 12 patients strategically selected from a randomised controlled trial on intensive care recovery from 10 Danish intensive care units. Data were generated during an ICU recovery programme including three consultations (at 1-3, 4-5, 9-11 months). First consultation was face-to-face using patient photographs to aid memory. Second and third consultations were by telephone using reflection sheets to focus dialogue. Thematic analysis and narrative theory were used to explore mechanisms of recovery using audio-recordings of consultations, patient photographs and reflection sheets as the sources of data.

RESULTS

The basic narrative of recovery was 'toward a trajectory of new orientation'. This narrative contained the chronological narratives of being 'at death's door', 'still not out of the woods' and 'on the road to recovery'. The road to recovery was described as downhill, steady-state or progressive. New orientation was obtained in steady-state or progressive recovery.

CONCLUSIONS

This study provides a contemporary understanding of the process of intensive care recovery. Recovery evolves through narratives of mortal danger, risk of relapse and moving forward towards a new orientation in life.

RELEVANCE TO CLINICAL PRACTICE

These findings enable health care professionals to understand what patients experience during stages of recovery. This is important to improve health care professionals in the assessment of long-term outcome, and management of patients after intensive care.

Developing a framework for implementing intensive care unit diaries: a focused review of the literature

OBJECTIVE

Intensive care unit diaries have been shown to improve post-critical illness recovery, however, prior reports of diary implementation are heterogeneous. We sought to construct a common framework for designing and implementing Intensive Care Unit diaries based on prior studies.

REVIEW METHOD USED/DATA SOURCES

We conducted a focused review of the literature regarding intensive care diaries based on a systematic search of several databases. Two reviewers assessed 56 studies and data were abstracted from a total of 25 eligible studies conducted between 1990 and 2014. We identified key information regarding the development, design, and implementation of the journals. We then grouped elements that appeared consistently across these studies within three main categories: (1) diary target populations; (2) diary format and content; and (3) the manner of diary return and follow-up.

RESULTS

Most studies were conducted in European countries in adult intensive care units and targeted patients in both medical and surgical units. The timing of diary initiation was based on the elapsed length of stay or duration of mechanical ventilation. We categorised diary format and content as: entry content, authors, use of standardised headings, type of language, initiation, frequency of entries, and physical location of diaries. Diaries were hand written and many studies found that photographs were an essential element in ICU diaries. We categorised the manner of diary return and follow-up. The context in which intensive care unit diaries were returned were felt to be important factors in improving the use of diaries in recovery.

CONCLUSIONS

In conclusion, we describe a common framework for the future development of intensive care unit diaries that revolves around the target population for the diaries, their format and content, and the timing of their use. Future studies should address how these elements impact the mechanisms by which intensive are diaries exert beneficial effects.

Diaries and memories following an ICU stay: a 2-month follow-up study

BACKGROUND

Many patients lack a clear recollection from their stay in the intensive care unit (ICU). Diaries have been introduced as a tool to complete memories and reduce the risk of posttraumatic stress disorder (PTSD).

AIMS

To describe and compare patients' memories and PTSD in relation to having received and read or not received a diary and patients' experiences of having received and read their diary, without having discussed the contents with ICU staff.

DESIGN

Descriptive and comparative.

METHODS

Patients received their diaries at ICU discharge. After 2 months patients answered the ICU Memory Tool, a screening instrument for PTSD (PTSS-14) and a questionnaire including space for own comments about the diaries.

RESULTS

Of 96 patients, 52(54%) received a diary, 44 did not. Patients with diaries had significantly longer stay and more mechanical ventilation. Of these, 40 patients responded to PTSS-14 and had evaluated and read the diary and 34 patients served as controls. No significant differences were found in presence/absence of memories between these groups. In the diary-group patients with emotional memories had lower APACHE. Feelings of being anxious or frightened were more common in the diary-group. At 2 months, 12% scored above cut-off on the PTSS14 with no difference between groups. The diaries were helpful for understanding the ICU-stay.

CONCLUSIONS

Diaries seem valuable in understanding what happened, as an act of caring and as a tool for discussion with relatives and friends. Patients valued reading their diaries. None expressed the wish to have read the diary together with a member of staff. The diary and non-diary groups however reported similar memories.

RELEVANCE TO CLINICAL PRACTICE

Diaries seem to be valuable in understanding what happened, giving a feeling of trust and for talking about their ICU-stay. As many patients described stressful memories, sessions should be offered with ICU staff.

Follow-up visit in an ICU: receiving a sense of coherence

AIM

To describe patients' experiences of a follow-up visit to an intensive care unit (ICU) after being critically ill and nursed there.

BACKGROUND

Knowledge about the follow-up visit needs to be developed, with the previously critically ill patient in focus.

DESIGN

Qualitative descriptive.

METHOD

Semi-structured interviews were conducted with nine patients and analysed using qualitative content analysis. The data collection occurred during spring 2014.

FINDINGS

During the follow-up visits in ICU, the relatives, the patient diary, and those who took part in the care contribute to fill memory gaps to create a picture and an explanation of the care period.

CONCLUSION

The follow-up visit is an important tool in the patients' struggle to create a context and coherence from a missing or unreal time. The patient diary is essential to subsequently be able to relate to the period of care.

RELEVANCE TO CLINICAL PRACTICE

The follow-up visit, together with a personal diary, after an ICU stay could be seen as significant for strengthening the patients' feeling of coherence and better health.

The use, prevalence and potential benefits of a diary as a therapeutic intervention/tool to aid recovery following critical illness in intensive care: a literature review

AIMS AND OBJECTIVES

To critically appraise the available literature and summarise the evidence related to the use, prevalence, purpose and potential therapeutic benefits of intensive care unit diaries following survivors' discharge from hospital and identify areas for future exploration.

BACKGROUND

Intensive care unit survivorship is increasing as are associated physical and psychological complications. These complications can impact on the quality of life of survivors and their families. Rehabilitation services for survivors have been sporadically implemented and lack an evidence base. Patient diaries in intensive care have been implemented in Scandinavia and Europe with the intention of filling memory gaps, enable survivors to set realistic recovery goals and cement their experiences in reality.

DESIGN

A review of original research articles.

METHODS

The review used key terms and Boolean operators across a 34-year time frame in: CIHAHL, Medline, Scopus, Proquest, Informit and Google Scholar for research reports pertaining to the area of enquiry. Twenty-two original research articles met the inclusion criteria for this review.

RESULTS

The review concluded that diaries are prevalent in Scandinavia and parts of Europe but not elsewhere. The implementation and ongoing use of diaries is disparate and international guidelines to clarify this have been proposed. Evidence which demonstrates the potential of diaries in the reduction of the psychological complications following intensive care has recently emerged. Results from this review will inform future research in this area.

CONCLUSIONS

Further investigation is warranted to explore the potential benefits of diaries for survivors and improve the evidence base which is currently insufficient to inform practice. The exploration of prospective diarising in the recovery period for survivors is also justified.

RELEVANCE TO CLINICAL PRACTICE

Intensive care diaries are a cost effective intervention which may yield significant benefits to survivors.

Extent and application of ICU diaries in Germany in 2014

BACKGROUND

Diaries written for patients in the Intensive Care Unit (ICU) have been used in many European countries since the early 1990s to support patients and their relatives in their understanding of the ICU experience. ICU diaries have been introduced in Germany since 2008 via the internet, newsletters, newspapers, lectures and publications in German nursing journals.

AIM

The aim of the study was to update our knowledge of the extent and application of ICU diaries in Germany in 2014.

DESIGN

The study had a prospective mixed methods multicenter design.

METHOD

All 152 ICUs in the two German federal states of Baden-Württemberg and Schleswig-Holstein were surveyed to identify units that had implemented ICU diaries. An additional 69 ICUs from other parts of Germany were included in the survey. We excluded diaries used in neonatal ICUs. Out of 43 units using diaries 14 were selected for semi-structured key-informant telephone-interviews on the application of ICU diaries.

RESULTS

According to the survey, 8 out of 152 ICUs in the two federal states of Baden-Württemberg and Schleswig-Holstein had implemented ICU diaries and another six were planning implementation. Another 35 ICUs in other areas of Germany had implemented diaries and three units were planning to do so. Interviews were conducted with nurses at 14 selected ICUs. Informants reported successful adaption of the diary concept to their culture, but variability in application. No units were identified where all nursing staff participated in keeping ICU diaries.

CONCLUSION

Six years after the introduction of ICU diaries, ICU nurses in Germany are becoming familiar with the concept. Nursing shortage and bureaucratic challenges have impeded the process of implementation, but the adaption of ICU diaries to German conditions appears to be successful and is still in progress.

RELEVANCE TO CLINICAL PRACTICE

Implementation of ICU diaries is feasible after adjusting for cultural and legal issues.