ICU survivors’ utilisation of diaries post discharge: A qualitative descriptive study

The diary in the intensive care unit: Concept analysis

INTRODUCTION

Admission to an intensive care unit can cause sequelae to both patients and family members. In some countries, the use of diaries is a preventive action.

AIM

This research proposes to critically examine the concept of 'Intensive Care Unit Diary' by analysing the current state of the scientific literature to develop a precise conception of this phenomenon in nursing practice, since there are multiple unknowns regarding its use and content.

METHOD

A bibliographic search was carried out in the PubMed, Cochrane Library, Scopus and CINAHL databases in January 2023. The terms used to search for their use and definitions in the databases included Nurse, Concept analysis, Family, Uci Diary, Patient Critical, Intensive Care Unit. We use Wilson's concept analysis, later developed by Walker and Avant.

RESULTS

The concept analysis shows that the 'ICU Diary' is a record made in colloquial language by health workers and relatives of the patient admitted to the intensive care unit. Aimed at the patient, with an empathic and reflective style, which offers a narrative of the process, daily life and the conduct or behaviour of the patient during his stay. It is a therapeutic tool led by nurses accepted by patients, families and professionals. Its use benefits the recovery process, reducing post-traumatic stress in family members and patients. It favours communication and the bond between nurses, family members and patients, helping to express feelings and emotions.

CONCLUSIONS

The concept of 'UCI Diary' is complex. Through Wilson's model, a clarification of the concept has been achieved, creating a starting point for more precise research on this phenomenon and its effects on patients, family members, professionals and the health system.

The role of intensive care unit diaries in the grieving process: A monocentric qualitative study

BACKGROUND

The growing importance of psychological recovery for patients and their families following intensive care unit (ICU) experiences in recent years cannot be overemphasized. The ICU diary is used to aid patients in reducing the prevalence of post-traumatic stress disorder, anxiety, and depression. The usefulness of maintaining a diary during the grieving process has not yet been thoroughly investigated.

AIM

To investigate the role of ICU diaries in the grief process experienced by family members of a person who died in the intensive care unit.

STUDY DESIGN

Nine family members of seven deceased ICU patients with an ICU diary were contacted and interviewed by phone using a semi-structured interview. A qualitative data analysis was performed using thematic synthesis.

SETTING

Italian general intensive care unit.

FINDINGS

Interviewed family members felt that the diary helped them during the grieving process. The return of diaries was desired by family members for support and to remember one's loved one. The diary helped them process their losses in various ways, including signs of evidence of care, emotional involvement, consideration, and coping with grief. Four main themes emerged from the analysis: writing the diary, reading the diary, talking about the diary, and the diary during the grieving process.

CONCLUSIONS

The overall perception of the ICU diary was positive. The diary mostly helped relatives to "give back something of what we lost". This study also affirms the positive link between ICU diaries and bereavement in Italian ICU. Further studies are required to confirm the usefulness of this tool in the grieving process.

RELEVANCE TO CLINICAL PRACTICE

The ICU diary can help patients' family members understand what happened to their loved one and play an important role in the grieving process. The diary served as a valuable source of information that aided in providing bereavement support to the family by helping them to gain a rational and emotional understanding of the patient's death.

The use and application of intensive care unit diaries: An instrumental multiple case study

AIMS AND OBJECTIVES

The study aim was to explore the use of an Intensive Care Unit (ICU) diary within four different ICUs units in Sweden and thereby contribute to practice guidelines regarding the structure, content and use of an ICU diary.

BACKGROUND

ICU diaries are used to aid psychological recovery among critical care patients, but differences remain in diary writing both within and across countries. Few studies have focused on the combined views and experiences of ICU patients, family members and nursing staff about the use of ICU diaries.

DESIGN

An instrumental multiple case study design was employed.

METHODS

Three focus groups interviews were carried out with 8 former patients and their family members (n = 5) from the research settings. Individual interviews were carried out with 2 patients, a family member and a nurse respectively. Observations, field notes, documentary analysis and conversations with nursing staff were also conducted. Consolidated criteria for reporting qualitative research (COREQ) was followed.

RESULTS

The qualitative findings firstly consisted of a matrix and descriptive text of the four ICU contexts and current practices. This highlighted that there were similarities regarding the aims and objectives of the diaries. However, differences existed across the case study sites about how the ICU diary was developed and implemented. Namely, the use of photographs and when to commence a diary. Second, a thematic analysis of the qualitative data regarding patients' and family members' use of the ICU diary, resulted in four themes: i) the diary was used to take in and fully understand the situation; ii) the diary was an opportunity to assimilate warm, personalised and human care; iii) the diary was used to manage existential issues; and iv) the diary was a tool in daily activities.

CONCLUSIONS

Analysis of the instrumental case study data led to the identification of core areas for inclusion in ICU diary practice guidelines.

The Impact of an Intensive Care Diary on the Psychological Well-Being of Patients and Their Family Members: Longitudinal Study Protocol

BACKGROUND

Thanks to medical and technological advancements, an increasing number of individuals survive admission to intensive care units. However, survivors often experience negative outcomes, including physical impairments and alterations in mental health. Anxiety, depression, cognitive impairments, post-traumatic stress disorders, and functional disorders are known collectively as post-intensive care syndrome (PICS). Among the key triggering factors of this syndrome, memory impairment appears to play a significant role.

AIMS

This study aims to evaluate the impact of an intensive care diary on the psychological well-being of patients and their relatives after discharge from the ICU.

DESIGN

Prospective observational study.

EXPECTED RESULTS

The results of this study evaluate the impact of an ICU diary on the quality of life of ICU survivors and their family members.

Timing of Exposure to ICU Diaries and Its Impact on Mental Health, Memories, and Quality of Life: A Double-Blind Randomized Control Trial

Optimal time for ICU diary delivery and impact on mental health (MH), anxiety-depression, post-traumatic stress symptoms (PTSS), quality of life (QOL), and memories is unclear. We evaluated the effect of ICU diaries, dispatched at different time points, on outcomes in an Indian cohort.

"A story with gaps": An interpretative phenomenological analysis of ICU survivors' experience

ICU survivors may experience various long-term sequelae, recognized as Post-Intensive Care Syndrome, that includes psychiatric symptoms: anxiety, depression, and post-traumatic stress disorders symptoms (PTSD). While it was hypothesized that an ICU diary could help patients after discharge, improving their hospitalization memories and quality of life, it is unclear whether it may reduce psychiatric disorders, in particular PTSD. We performed a qualitative exploration of survivors' subjective experience of their ICU stay, their representations, memories, meaning-making of their experience and use of their ICU diary. Five participants (ICU survivors, 3 men and 2 women, who received a diary) were included in this study. We conducted non-directive interviews 6 months after discharge. These interviews were transcribed and analyzed using Interpretative Phenomenological Analysis. Major recurring themes of discourse included: (1) The nightmare of the ICU experience: from an impression of vagueness to dispossession, (2) The positive image of health-care workers during intensive care, (3) The place of the relatives and health-care workers' writings in the diary: either a support or a barrier, (4) The difficult return back home, and daily life after intensive care. Participant's representation of their ICU experience seemed to reflect the meaning they had given it through their own reflections and that of health-care workers in the diary. For some participant, the diary was associated to the pain and strangeness of the ICU experience; therefore, their recovery required them to take some distance with it. The ICU diary allowed participants to construct their illness narratives, and to become aware of the presence and support of health-care workers. The diary was also perceived as the witness of a period they wished to forget. Trial registration: NCT02519725.

Implementation of paediatric intensive care unit diaries: Feasibility and opinions of parents and healthcare providers

BACKGROUND

The implementation of paediatric intensive care unit (PICU) diaries has been reported as feasible in routine care. To date no feasibility study has compared PICU healthcare providers' (HCPs) and parents' opinions on this tool.

OBJECTIVES

The aim of this study is to describe the feasibility and perception of PICU diaries in an Italian PICU from the point of view of parents and HCPs.

METHODS

This is a single-centre, prospective, observational study conducted in a tertiary care paediatric hospital from August 2020 to May 2021. Children admitted to the emergency department PICU, intubated, and sedated for ≥48 h were enrolled. To explore their perceptions and attitudes with the PICU diary, parents were interviewed at 30 days from their child's discharge from the PICU, whereas PICU HCPs were surveyed at the end of the study. Data were analysed as proportions for categorical variables and means and medians for continuous variables according to the distribution, whereas qualitative data were summarised in categories by two independent researchers.

RESULTS

Twenty families were enrolled in this study. A total of 275 daily PICU diary entries were collected. Children's median age was 9 years (interquartile range = 2-13.25), and the length of stay ranged from 6 to 39 days. PICU diary applicability was rated high by parents and HCPs (>8 on a 1-10 Likert scale). Parents and HCPs perceived PICU diaries as beneficial for communication between staff and families, for parents by expressing their emotions and for staff by becoming aware of how parents experienced their child's admission. Reported barriers were the lack of a private environment, the risk of exposure to public reading, and PICU workload.

CONCLUSIONS

PICU diaries were feasible and perceived as beneficial both by parents and HCPs. Future research is warranted to understand the effect of PICU diaries on post-PICU outcomes.

Processing Intensive Care Unit Treatment Experiences: A Thematic Analysis of a Diary Intervention

Survivors of the intensive care unit (ICU) report an aggregate of burdensome memories. ICU diaries have been proposed to address the psychological impact of ICU treatment. Twenty-six participants wrote about their ICU experiences in three successive sessions, while in the second session, they were presented with a dairy derived from their medical records. Using inductive thematic analysis in the first and third narratives, we explore how participants initially describe their ICU experience and how they process it after the intervention. Participants described a martyrdom experience, including being emotionally distressed, disorientated, and physically trapped that provoked a quest for any available interpersonal support. A vacuum-like state permeated their existence, impacted their sense-making ability, and the proximity to death uniquely characterized this experience. After intervention, participants made small but significant changes in their written narratives. They appeared to reorganize their recollections, reestablish self-continuity by integrating their ICU experiences, and authored restitution narratives.

Report on the Third International Intensive Care Unit Diary Conference

TOPIC

Many patients in intensive care units have frightening experiences and memories and subsequent post-intensive care syndrome, with psychiatric morbidity including depression, anxiety, and posttraumatic stress disorder. Intensive care unit diaries, written by staff members and families, support patients' understanding of what occurred and may alleviate their psychological suffering.

CLINICAL RELEVANCE

An increasing number of critical care nurses in the United States and elsewhere are implementing intensive care unit diaries, but implementation remains challenging.

PURPOSE

To address emerging questions and support implementation in the United States, we held the Third International Intensive Care Unit Diary Conference as a 1-day preconference during the Seventh Annual Johns Hopkins Critical Care Rehabilitation Conference on November 1, 2018, in Baltimore, Maryland. This article summarizes the conference.

CONTENT COVERED

Conference presentations included intensive care unit-related experiences of patients and families, psychosocial aspects of post-intensive care syndrome, the evolution of diaries, implementation strategies for intensive care unit diaries, special topics (eg, legal issues, electronic vs handwritten diaries, pediatric diaries, and time of handover), and psychosocial recovery.

Intensive care unit diaries to help bereaved family members in their grieving process: a systematic review

BACKGROUND

Intensive care unit diaries are often used to support patients during their psychological recovery. The intensive care unit stay can be upsetting, disturbing and traumatic for both patients and their families especially when the patient does not survive.

AIM

To investigate the connection between intensive care unit diaries and the grieving process experienced by family members of adult patients deceased in the intensive care unit.

METHODS

Systematic literature review according to PRISMA guidelines: PubMed, CINAHL and Cochrane Library were consulted. The Caldwell's framework was used for the quality appraisal.

RESULTS

Only six studies examine this topic. The potential benefits of intensive care unit diaries in family members' bereavement process may be an aid to realise how extremely ill their loved one was, may provide comfort and may help relatives to cope with their loss.

CONCLUSION

The use of intensive care unit diaries to help family members' bereavement process may be a useful tool but further research is necessary to better understand their role and benefits.

Narrative diaries in the paediatric intensive care unit: A thematic analysis

BACKGROUND

The paediatric intensive care unit (PICU) diary is a shared tool, kept at the patient bedside, written by relatives and health care providers. There is little evidence about its feasibility and how it supports the families of children admitted to the PICU. Currently, there is no evidence about how the PICU diary is used and what we can learn from it.

AIM

To explore the contents of narrative PICU diaries in an Italian PICU.

STUDY DESIGN

Qualitative study of PICU diaries conducted with a narrative research approach.

METHODS

Children sedated and mechanically ventilated for >48 hours were enrolled in a six-bed Italian PICU of a tertiary care paediatric hospital. During the child's PICU admission, caregivers, relatives, friends, and health care providers were invited to report events, thoughts, and messages, and attach drawings/pictures for the child in the PICU diary. A thematic analysis of the PICU diary contents was performed.

RESULTS

Thirteen PICU diaries were completed between August and December 2020, mainly by parents (n = 95; 45%) and health care providers (n = 52; 25%). Three main themes emerged: "Social and spiritual support," "Caregiver's emotions, feelings and distress," and "PICU life." Diaries offer insight into caregivers' emotions, social support, clinical activities, and interactions with health care providers, and on progression towards recovery.

CONCLUSION

PICU diaries are valuable in facilitating family-centred care by providing a space for the written account of the child's admission by parents, other visitors, and health care providers.

RELEVANCE TO CLINICAL PRACTICE

PICU diaries support the relationship and the communication between the family and the team; they provide an informal account of the emotions and needs of parents that has the potential to improve mutual understanding and family-centred care. Social support and spiritual support are key elements reported by parents for coping with their child's PICU admission.

Exploring family members' and health care professionals' perceptions on ICU diaries: a systematic review and qualitative data synthesis

PURPOSE

Although the intensive care unit (ICU) diary has been proposed as a tool for preventing psychiatric symptoms in survivors of critical illness, relatives and health care providers may benefit from it too. This study aims to summarize the current qualitative evidence on families' and health care professionals' experiences of writing in and reading the ICU diaries.

METHODS

We searched MEDLINE, OVID, Embase, and EBSCOhost from inception to February 2021, and included all the studies that presented any qualitative finding regarding relatives' and health care providers' experiences of writing in and reading an ICU diary. We used modified Critical Appraisal Skills Programme (CASP) and Confidence in the Evidence from Reviews of Qualitative Research (CERQual) for quality assessment. A thematic synthesis approach was used to analyze and synthesize the qualitative data.

RESULTS

Twenty-eight studies were analyzed (15 including family members and 13 including health care professionals). For family members, the ICU diary is an important source of medical information, provides a way for them to register their presence at patient's bedside and express their feelings, and contributes to humanizing the ICU staff. This impression is shared by relatives of patients who did not survive critical illness. Health care providers believe the diary is beneficial for themselves and others; however, they are concerned with possible negative impressions from patients and family that could lead to judicial problems. They also remark on several obstacles they face when constructing the diaries (workload, creativity, and environment for writing), which can make it a distressful process.

CONCLUSION

This qualitative synthesis shows that family members and health care professionals consider the ICU diary a valuable intervention. It also brings evidence to challenges faced during diary writing, which should be carefully approached in order to reduce the stress associated with this process.

ICU Survivors Experience of ICU Diaries: An Ancillary Qualitative Analysis of the ICU Diary Study

Supplemental Digital Content is available in the text.

OBJECTIVES:

To investigate patients’ experience of ICU diaries 6 months after ICU discharge among survivors. This study was designed to add insight into a large randomized study, which found no benefit of the ICU diary to post-traumatic stress disorder among critically ill patients having received mechanical ventilation.

DESIGN:

A preplanned qualitative substudy of patients receiving an ICU diary written by ICU caregivers and families. Six months after ICU discharge, survivors were contacted by a psychologist for a telephone interview using a semi-directive guide.

SETTING:

Thirty-five French ICUs.

PATIENTS:

All ICU survivors having received an ICU diary.

INTERVENTION:

An ICU diary written by both ICU staff and families.

MEASUREMENTS AND MAIN RESULTS:

Among the 332 patients randomized in the intervention group (having had an ICU diary filled by both ICU staff and families), 191 (57.7%) were alive at 6 months and 101 of 191 (52.9%) participated in a telephone interview. They were (median [interquartile range]) 64 years old (53–70 yr old); 65 (64.4%) were men, and 79 (78.2%) were medical patients. Duration of ICU stay was 13 days (8–21 d). Three themes were derived from the thematic analysis: 1) reading the diary: between emotion and pain, 2) how the diary helped, and 3) the bittersweet representation of the diary. For half of the patients, the diary is a good memory of difficult times (55/101, 54.5%), others seem to be more ambivalent about it (28/101, 27.8%), and 37 of 101, 36.6% see it as a painful representation of a time to be forgotten.

CONCLUSIONS:

When reading their ICU diaries, ICU survivors experienced mixed emotions, related to family messages, medical caregiving, and to the severity of their illness. Patients described diaries as a help or a hindrance to recovery, depending on their wish to remember the period or move on from it.

Theorising survivorship after intensive care: A systematic review of patient and family experiences

AIMS AND OBJECTIVE

This systematic literature review explores and maps what we know about survivorship to understand how survivorship can be theoretically defined.

BACKGROUND

Survivorship of critical illness has been identified as a challenge for the 21st Century. Whilst the use of the term 'survivorship' is now common in critical care, it has been borrowed from the cancer literature where the discourse on what survivorship means in a cancer context is ongoing and remains largely descriptive. In the absence of a theoretical understanding, the term 'survivorship' is often used in critical illness in a generic way, limiting our understanding of what survivorship is. The current COVID-19 pandemic adds to an urgency of understanding what intensive care unit (ICU) survivorship might mean, given the emerging long-term consequences of this patient cohort. We set out to explore how survivorship after critical illness is being conceptualised and what the implications might be for clinical practice and research.

DESIGN

Integrated systematic literature review. The review protocol was registered with PROSPERO International Prospective Register of Systematic Reviews. PRISMA guidelines were followed and a PRISMA checklist for reporting systematic reviews completed.

RESULTS

The three main themes around which the reviewed studies were organised are: (a) healthcare system; (b) ICU survivors' families; and (c) ICU survivor's identity. These three themes feed into an overarching core theme of 'ICU Survivorship Experiences'. These themes map our current knowledge of what happens when a patient survives a critical illness and where we are in understanding ICU survivorship.

CONCLUSION

We mapped in this systematic review the different pieces of the jigsaw that emerge following critical illness to understand and see the bigger picture of what happens after patients survive critical illness. It is evident that existing research has mapped these connections, but what we have not managed to do yet is defining what survivorship is theoretically. We offer a preliminary definition of survivorship as a process but are aware that this definition needs to be developed further with patients and families.

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.

The experience of relatives using intensive care diaries: A systematic review and qualitative synthesis

BACKGROUND

Intensive care patient diaries written by staff and/or relatives are widely used in intensive care units (ICUs) across the world. Although the original aim of the diaries was to support patients in their recovery from ICU, a more recent focus of the literature has been the potential benefit of the diaries to the relatives of patients. Meta-analyzes of quantitative studies looking at the impact on the psychological wellbeing of relatives have not consistently found an effect of the diaries, even though qualitative studies suggest that relatives find the diaries to be a useful coping strategy.

OBJECTIVES

To evaluate and synthesise qualitative studies looking at the experience of relatives writing in ICU diaries.

DESIGN

A systematic review and qualitative synthesis.

DATA SOURCES

A structured search using CINAHL, MEDLINE, PsycInfo, Cochrane Central Register of Controlled Trials (CENTRAL), PTSDHubs and Published International Literature Web of Science Conference Proceedings Citation Index - Science and Social Science and Humanities was conducted.

REVIEW METHODS

All studies published at any time that included qualitative data (including mixed methods studies) about the perceptions of relatives using ICU patient diaries were included. Themes and narrative statements were extracted from included articles and synthesised. Articles were quality assessed using the Critical Appraisal Skills Programme (CASP) qualitative checklist and Mixed Methods Appraisal Tool (MMAT).

RESULTS

Sixteen studies were included in the review, thirteen qualitative and three mixed methods articles. The themes identified were: 1. Coping (subthemes: 1.1. Emotion-Focused Coping and 1.2. Problem-Focused Coping) 2. Connection (subthemes: 2.1 Method of Communication and 2.2 Developing and maintaining relationships) 3. Developing a Narrative (subthemes 3.1 Understanding 3.2 Shaping the story 3.3 Remembering).

CONCLUSIONS

Relatives use the diaries in a variety of ways including as a means of coping, a way of staying connected, as a tool to understand and develop a narrative about the experience. These findings link the use of ICU diaries with literature on written emotional exposure, post-traumatic growth and meaning making. The relationship between a relative's use of the ICU diary, coping strategies and/or post-traumatic growth could be a focus for future quantitative trials. PROSPERO protocol number CRD42020165869.

Original Research: Exploring the Effects of a Nurse-Initiated Diary Intervention on Post-Critical Care Posttraumatic Stress Disorder

BACKGROUND

Critical illness survivors may develop posttraumatic stress disorder (PTSD) following critical illness and hospitalization. Left untreated, PTSD may result in poor health outcomes.

PURPOSE

This study sought to examine the effects of a nurse-initiated diary intervention on PTSD development and symptom severity in critical illness survivors with varying levels of mentation.

METHODS

The study used a pretest-posttest control group design. Patients who were hospitalized in a critical care unit for more than 24 hours were recruited at a single medical center with two such units. All participants completed a pretest on day 2 of critical care hospitalization; the intervention group participants also received a diary. All participants received a posttest one month after critical care discharge. The variables examined were PTSD severity and symptoms of avoidance, intrusion, and hyperarousal. Variables were measured using the Impact of Event Scale-Revised. Diaries were written by the patient, visitors, and interdisciplinary team members, and kept by the patient.

RESULTS

A total of 134 participants completed the study. The intervention group participants experienced significantly fewer PTSD symptoms than the control group participants. PTSD was found to be of concern in 35 (26%) of all participants: five in the intervention group and 30 in the control group.

CONCLUSIONS

For critical illness survivors, a collaborative diary-writing intervention during hospitalization and after discharge can mitigate post-critical care PTSD. Participants who received diaries had a lower incidence of PTSD symptoms than controls; and at follow-up, they indicated that the diary intervention was worthwhile. We recommend the use of collaborative diary writing to help critical illness survivors in working through their experiences.

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.

"Not in My House": Perspectives on HIV/AIDS of Afro-Caribbean Adolescents Living in South Florida

Florida has the highest number of PLWH in the USA, with the highest incidence being among young African-Americans. The purpose of this qualitative inquiry was to gain an understanding of the knowledge and attitudes to HIV/AIDS among Afro-Caribbean adolescents. Using a faith-based community, we conducted four focus group sessions with 40 Afro-Caribbean teens. Descriptive content and thematic analyses were used to examine the data. Themes identified include awareness gap, temptation everywhere, testing anxiety and stigma. Recommendations include continued exploration and interventions to address stigma in faith-based communities. Implications are discussed.

States worse than death

PURPOSE OF REVIEW

This review aims to discuss situations where patients would prefer to consider dying rather than survive, particularly in the context of choosing whether to be subjected to active medical management aimed at increasing their life span.

RECENT FINDINGS

Obviously, there are no randomized trials on evaluating whether patients would choose death rather than life. Moreover, the topic of the review is rarely addressed in a conventional scientific way. Instead, we review the suffering that people may go through when receiving futile care in both the short and long-term in acute hospitals and how this may influence people's decisions about their own Goals of Care.

SUMMARY

The review describes the failure of acute hospitals to recognize people at the end of life until very late and, when they are recognized, the failure to manage the dying process well. The inference is that if patients were genuinely aware of the potential short and long-term suffering involved in futile care, they would consider those states worse, may be worse than death, especially when death is almost certainly inevitable with or without conventional treatment.

Effect of an ICU Diary on Posttraumatic Stress Disorder Symptoms Among Patients Receiving Mechanical Ventilation: A Randomized Clinical Trial

IMPORTANCE

Keeping a diary for patients while they are in the intensive care unit (ICU) might reduce their posttraumatic stress disorder (PTSD) symptoms.

OBJECTIVES

To assess the effect of an ICU diary on the psychological consequences of an ICU hospitalization.

DESIGN, SETTING, AND PARTICIPANTS

Assessor-blinded, multicenter, randomized clinical trial in 35 French ICUs from October 2015 to January 2017, with follow-up until July 2017. Among 2631 approached patients, 709 adult patients (with 1 family member each) who received mechanical ventilation within 48 hours after ICU admission for at least 2 days were eligible, 657 were randomized, and 339 were assessed 3 months after ICU discharge.

INTERVENTIONS

Patients in the intervention group (n = 355) had an ICU diary filled in by clinicians and family members. Patients in the control group (n = 354) had usual ICU care without an ICU diary.

MAIN OUTCOMES AND MEASURES

The primary outcome was significant PTSD symptoms, defined as an Impact Event Scale-Revised (IES-R) score greater than 22 (range, 0-88; a higher score indicates more severe symptoms), measured in patients 3 months after ICU discharge. Secondary outcomes, also measured at 3 months and compared between groups, included significant PTSD symptoms in family members; significant anxiety and depression symptoms in patients and family members, based on a Hospital Anxiety and Depression Scale score greater than 8 for each subscale (range, 0-42; higher scores indicate more severe symptoms; minimal clinically important difference, 2.5); and patient memories of the ICU stay, reported with the ICU memory tool.

RESULTS

Among 657 patients who were randomized (median [interquartile range] age, 62 [51-70] years; 126 women [37.2%]), 339 (51.6%) completed the trial. At 3 months, significant PTSD symptoms were reported by 49 of 164 patients (29.9%) in the intervention group vs 60 of 175 (34.3%) in the control group (risk difference, -4% [95% CI, -15% to 6%]; P = .39). The median (interquartile range) IES-R score was 12 (5-25) in the intervention group vs 13 (6-27) in the control group (difference, -1.47 [95% CI, -1.93 to 4.87]; P = .38). There were no significant differences in any of the 6 prespecified comparative secondary outcomes.

CONCLUSIONS AND RELEVANCE

Among patients who received mechanical ventilation in the ICU, the use of an ICU diary filled in by clinicians and family members did not significantly reduce the number of patients who reported significant PTSD symptoms at 3 months. These findings do not support the use of ICU diaries for preventing PTSD symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02519725.

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.

Nursing staff's experiences of intensive care unit diaries: a qualitative study

BACKGROUND

Diaries as an intervention to aid psychological recovery among intensive care patients have been used for about 20 years, and findings tend to be positive. The provision of a diary directed at the patient may clarify the story of the intensive care unit (ICU) even for the family members and the family members of non-survivors. Members of nursing staff are the primary authors, but how they themselves experience the use of ICU diaries has been minimally explored.

AIMS AND OBJECTIVES

This study aimed to explore how nursing staff experienced the use of ICU patient diaries.

DESIGN

Qualitative design using focus group interviews.

METHODS

A qualitative methodology was used. Six focus group interviews were conducted with 27 nursing staff recruited from one university and two county hospitals. The data were analysed via thematic content analysis.

FINDINGS

One overarching theme, 'An effort to do good in words and actions', and four interconnected themes were derived from the analysis. By creating the diary, nursing staff had to deal with a variety of ethical and practical dilemmas, but feedback from patients, family members and ICU follow-up services reinforced the feeling of doing good. This overarching feeling of beneficence encouraged diary authoring and increased motivation and commitment to strive towards excellent patient care. To sustain the use of ICU diaries, collegiate and organizational support was deemed essential.

CONCLUSIONS

Nursing staff strived to do good in words and actions for patients and their families when writing the diaries. Positive feedback from patients, family members and ICU follow-up services reinforced feelings of doing good, which served to enhance work satisfaction and a commitment to good-quality nursing care. Experiential-based education was recommended to help sustain ICU diary writing.

RELEVANCE TO CLINICAL PRACTICE

Nursing staff requested mentoring and group discussions concerning the format, content and communication channels of the diary.

Implementing Family-Centered Care Through Facilitated Sensemaking

The Society of Critical Care Medicine has released updated recommendations for care of the family in neonatal, pediatric, and adult intensive care units. Translation of the recommendations into practice may benefit from a supporting theoretical framework. Facilitated sensemaking is a mid-range theory built from the same literature that formed the basis for recommendations within the guidelines. The process of facilitated sensemaking may be used to help nurses adopt the SCCM recommendations into practice through the development of caring relationships, promoting family presence, teaching family engagement strategies, and supporting families with communication, information gathering, and participation in decision-making.

Group meetings after critical illness-Giving and receiving strength

INTRODUCTION

An increasing number of intensive care patients are surviving critical illness, but many develop mental, cognitive and physical impairments after discharge. Adapting to a new life situation, often with major challenges, implies the need of support. Therefore, it is important to develop interventions aimed at promoting recovery.

OBJECTIVE

The aim was to describe former intensive care patients' feelings of sharing their experience of critical illness with other former patients.

METHOD

Former intensive care patients (n = 17) participated in group meetings and wrote about their thoughts in a notebook after each group meeting. To deepen the understanding of the former patients' experience 11 of the former patients were interviewed. The notes in the notebooks and the interviews were analysed using qualitative content analysis.

FINDINGS

Meeting others revealed to the former patients new dimensions of being critically ill, and they both gave and received strength from each other. The meetings were meaningful as they gained insight into other patients' lives, and realised what it meant to survive intensive care.

CONCLUSIONS

The group meetings meant sharing experiences and understanding the process of survival after critical illness. Giving and receiving strength from others helped the participants to go further.

Perspectives of patients and family members regarding psychological support using intensive care diaries: An exploratory mixed methods study

PURPOSE

Diaries summarizing intensive care are routine practice in some countries, although evidence to support diary use is limited. The purpose of this study was to identify whether distress post-intensive care influences patients' and relatives' choice as to whether they would like to receive a diary and what information delivery method is preferred.

MATERIALS AND METHODS

Intensive care patients admitted for at least 3 days and their relatives participated in an exploratory mixed methods study. Interviews were conducted 3 to 5 months after discharge. Psychological distress was assessed using Kessler-10 and Posttraumatic Stress Disorder Symptom Checklist - 5. Perceptions of benefit of diaries were assessed using a 4-point Likert scale. Differences were examined using Fisher exact test (P<.05).

RESULTS

Fifty-seven patients and 22 relatives consented to participation, with 22 patients and 22 relatives interviewed before data saturation. Psychological distress was evident in 25 (47%) patients and 5 (23%) relatives. Participants' psychological health was similar for those who perceived diaries as beneficial, and those who did not. Themes included memory, process, and impact, although opinions were diverse.

CONCLUSIONS

Patient and relative preferences of receiving a diary are not related to psychological distress. Diverse opinions around common themes suggest the need for a range of interventions to aid psychological recovery.

Patient outcomes after critical illness: a systematic review of qualitative studies following hospital discharge

BACKGROUND

There is growing interest in patient outcomes following critical illness, with an increasing number and different types of studies conducted, and a need for synthesis of existing findings to help inform the field. For this purpose we conducted a systematic review of qualitative studies evaluating patient outcomes after hospital discharge for survivors of critical illness.

METHODS

We searched the PubMed, EMBASE, CINAHL, PsycINFO, and CENTRAL databases from inception to June 2015. Studies were eligible for inclusion if the study population was >50 % adults discharged from the ICU, with qualitative evaluation of patient outcomes. Studies were excluded if they focused on specific ICU patient populations or specialty ICUs. Citations were screened in duplicate, and two reviewers extracted data sequentially for each eligible article. Themes related to patient outcome domains were coded and categorized based on the main domains of the Patient Reported Outcomes Measurement Information System (PROMIS) framework.

RESULTS

A total of 2735 citations were screened, and 22 full-text articles were eligible, with year of publication ranging from 1995 to 2015. All of the qualitative themes were extracted from eligible studies and then categorized using PROMIS descriptors: satisfaction with life (16 studies), including positive outlook, acceptance, gratitude, independence, boredom, loneliness, and wishing they had not lived; mental health (15 articles), including symptoms of post-traumatic stress disorder, anxiety, depression, and irritability/anger; physical health (14 articles), including mobility, activities of daily living, fatigue, appetite, sensory changes, muscle weakness, and sleep disturbances; social health (seven articles), including changes in friends/family relationships; and ability to participate in social roles and activities (six articles), including hobbies and disability.

CONCLUSION

ICU survivors may experience positive emotions and life satisfaction; however, a wide range of mental, physical, social, and functional sequelae occur after hospital discharge. These findings are important for understanding patient-centered outcomes in critical care and providing focus for future interventional studies aimed at improving outcomes of importance to ICU survivors.

Characteristics of Qualitative Descriptive Studies: A Systematic Review

Qualitative description (QD) is a term that is widely used to describe qualitative studies of health care and nursing-related phenomena. However, limited discussions regarding QD are found in the existing literature. In this systematic review, we identified characteristics of methods and findings reported in research articles published in 2014 whose authors identified the work as QD. After searching and screening, data were extracted from the sample of 55 QD articles and examined to characterize research objectives, design justification, theoretical/philosophical frameworks, sampling and sample size, data collection and sources, data analysis, and presentation of findings. In this review, three primary findings were identified. First, although there were some inconsistencies, most articles included characteristics consistent with the limited available QD definitions and descriptions. Next, flexibility or variability of methods was common and effective for obtaining rich data and achieving understanding of a phenomenon. Finally, justification for how a QD approach was chosen and why it would be an appropriate fit for a particular study was limited in the sample and, therefore, in need of increased attention. Based on these findings, recommendations include encouragement to researchers to provide as many details as possible regarding the methods of their QD studies so that readers can determine whether the methods used were reasonable and effective in producing useful findings. © 2016 Wiley Periodicals, Inc.

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.

Making sense of it: intensive care patients' phenomenological accounts of story construction

BACKGROUND

Patients entering intensive care encounter physical and psychological stress that may lead to psychological morbidity such as depression, anxiety and post-traumatic stress. It has been suggested that constructing a story may assist psychological recovery. However, this has been minimally investigated in intensive care patients.

AIM

The aim of this article is to examine the process of story construction in people's phenomenological accounts of being a patient in the technological environment of intensive care.

STUDY DESIGN

The study design was informed by Heideggerian phenomenology.

METHODS

Semi-structured interviews were conducted with 19 patients who had been in intensive care for at least 4 days. Interviews were digitally recorded, transcribed and analysed utilizing Van Manen's framework for thematic analysis.

FINDINGS

Making sense of their experiences in an intensive care unit appeared to be fundamental to story construction. Themes that arose were 'why am I here?', 'filling in the gaps', 'sorting the real from the unreal' and 'searching for familiarity'. These themes describe how participants sought temporal and causal coherence in order to construct their integrated and understandable story. Families appeared to play a critical role in helping participants fill in the gaps, sorting the real from the unreal and their subsequent psychological recovery.

CONCLUSIONS AND RELEVANCE TO CLINICAL PRACTICE

The importance of early support from health care professionals to facilitate patients' story construction is highlighted. The study also emphasizes the role families play in supporting patients while they make sense of their experiences and the associated psychological recovery process. Further research to evaluate methods of facilitating story construction, such as nurse-led debriefing and patient diaries, is recommended. In addition, an investigation of families' perceptions of their role in assisting patients construct their story may facilitate the development of strategies by health care professionals to effectively support families in their role.

Moving on in life after intensive care--partners' experience of group communication

BACKGROUND

Partners have a burdensome time during and after their partners' intensive care period. They may appear to be coping well outwardly but inside feel vulnerable and lost. Evaluated interventions for partners on this aspect are limited.

AIM

The aim of this study was to describe the experience of participating in group communication with other partners of former intensive care patients.

DESIGN

The study has a descriptive intervention-based design where group communication for partners of former, surviving intensive care unit (ICU) patients was evaluated.

METHODS

A strategic selection was made of adult partners to former adult intensive care patients (n = 15), 5 men and 10 women, aged 37-89 years. Two group communication sessions lasting 2 h were held at monthly intervals with three to five partners. The partners later wrote, in a notebook, about their feelings of participating in group communications. To deepen the understanding of the impact of the sessions, six of the partners were interviewed. Content analysis was used to analyse the notebooks and the interviews.

FINDINGS

Three categories were identified: (1) Emotional impact, the partners felt togetherness and experienced worries and gratitude, (2) Confirmation, consciousness through insight and reflection and (3) The meeting design, group constellation and recommendation to participate in group communication.

CONCLUSION

Partners of an intensive care patient are on a journey, constantly trying to adapt to the new situation and find new strategies to ever-changing circumstances. Group communications contributed to togetherness and confirmation. To share experiences with others is one way for partners to be able to move forward in life.

RELEVANCE TO CLINICAL PRACTICE

Group communication with other patients' partners eases the process of going through the burden of being a partner to an intensive care patient. Group communications needs to be further developed and evaluated to obtain consensus and evidence for the best practice.

Family members' experiences of keeping a diary during a sick relative's stay in the intensive care unit: a hermeneutic interview study

OBJECTIVE

The aim of the study was to explore family members' experiences with keeping a diary during a sick relative's stay in the ICU.

DESIGN

A qualitative method with a hermeneutic approach was used. Eleven participants, who recorded nine diaries in total, were interviewed. The collected data were analysed using a hermeneutic approach inspired by Gadamer.

RESULTS

The analysis revealed a meta-theme: 'it [writing in the diary] felt like contact' which was created by a feeling of togetherness and the opportunity to communicate with the patient. Keeping a diary likely meets the needs of family members in several ways because it becomes a way to be present at the patient's bedsides, to provide caregiving, to maintain hope and to relay cogent information. However, concerns regarding negative aspects of diary keeping were also raised; for example, the diary created feelings of stress, guilt and failure and exposed intimate details.

CONCLUSION

The diary symbolised the maintenance of relationships with the patients and was a substitute for the usual opportunities for communication. Furthermore, it was instrumental in meeting the needs of the majority of family members in several ways. Nevertheless, the diary did have negative effects for certain individuals, which highlights the importance of an individualised approach.

The psychological and neurocognitive consequences of critical illness. A pragmatic review of current evidence

Mortality rates alone are no longer a sufficient guide to quality of care. Due to medical advances, patients are surviving for longer following critical illness and major surgery; therefore, functional outcomes and long-term quality of life are of increasing consequence. Post-operative cognitive dysfunction has been acknowledged as a complication following anaesthesia for many years, and interest in persistent cognitive dysfunction following a critical illness is growing. Psychological and neurocognitive sequelae following discharge from intensive care are acknowledged to occur with sufficient significance to have recently coined the term 'the post-intensive care syndrome'. Rehabilitation following critical illness has been highlighted as an important goal in recently published national UK guidelines, including the need to focus on both physical and non-physical recovery. Neuropsychological and cognitive consequences following anaesthesia and critical illness are significant. The exact pathophysiological mechanisms linking delirium, cognitive dysfunction and neuropsychological symptoms following critical illness are not fully elucidated but have been studied elsewhere and are outside the scope of this article. There is limited evidence as yet for specific peri-operative preventative strategies, but early management and rehabilitation strategies following intensive care discharge are now emerging. This article aims to summarise the issues and appraise current options for management, including both neuroprotective and neurorehabilitative strategies in intensive care.

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.

Writing in and reading ICU diaries: qualitative study of families' experience in the ICU

Purpose

Keeping an ICU patient diary has been reported to benefit the patient's recovery. Here, we investigated the families' experience with reading and writing in patient ICU diaries kept by both the family and the staff.

Methods

We conducted a qualitative study involving 32 semi-structured in-depth interviews of relatives of 26 patients (34% of all family members who visited patients) who met our ICU-diary criterion, i.e., ventilation for longer than 48 hours. Grounded theory was used to conceptualise the interview data via a three-step coding process (open coding, axial coding, and selective coding).

Results

Communicative, emotional, and humanising experiences emerged from our data. First, family members used the diaries to access, understand, and assimilate the medical information written in the diaries by staff members, and then to share this information with other family members. Second, the diaries enabled family members to maintain a connection with the patient by documenting their presence and expressing their love and affection. Additionally, families confided in the diaries to maintain hope. Finally, family members felt the diaries humanized the medical staff and patient.

Conclusions

Our findings indicate positive effects of diaries on family members. The diaries served as a powerful tool to deliver holistic patient- and family-centered care despite the potentially dehumanising ICU environment. The diaries made the family members aware of their valuable role in caring for the patient and enhanced their access to and comprehension of medical information. Diaries may play a major role in improving the well-being of ICU-patient families.

Never ending stories: visual diarizing to recreate autobiographical memory of intensive care unit survivors

AIM

The aim of this study was to explore the potential use of visual diarizing to enable intensive care unit (ICU) survivors to create their story of recovery.

BACKGROUND

An ICU experience can have deleterious psychological and physical effects on survivors leading to reductions in quality of life which for some may be of significant duration. Although there has been exploration of many interventions to support recovery in this group, service provision for survivors remains inconsistent and inadequate.

DESIGN AND PARTICIPANTS

A qualitative interpretive biographical exploration of the ICU experience and recovery phase of ICU survivors using visual diarizing as method. This paper is a component of a larger study and presents an analyses of one participant's visual diary in detail.

METHODS

Data collection was twofold. The participant was supplied with visual diary materials at 2 months post-hospital discharge and depicted his story in words and pictures for a 3-month period, after which he was interviewed. The interview enabled the participant and researcher to interpret the visual diary and create a biographical account of his ICU stay and recovery journey.

FINDINGS

The analysis of one participant's visual diary yielded a wealth of information about his recovery trajectory articulated through the images he chose to symbolize his story. The participant confirmed feelings of persecution whilst in ICU and was unprepared for the physical and psychological disability which ensued following his discharge from hospital. However, his story was one of hope for the future and a determination that good would come out of his experience. He considered using the visual diary enhanced his recovery.

CONCLUSIONS

The participant perceived that visual diarizing enhanced his recovery trajectory by enabling him to recreate his story using visual imagery in a prospective diary.

RELEVANCE TO CLINICAL PRACTICE

Prospective visual diarizing with ICU survivors may have potential as an aid to recovery.