ICU patients' recall of emotional reactions in the trajectory from falling critically ill to hospital discharge: follow-ups after 3 and 12 months

Development, feasibility testing, and preliminary evaluation of the Communication with an Artificial airway Tool (CAT): Results of the Crit-CAT pilot study

BACKGROUND

A purpose-built outcome measure for assessing communication effectiveness in patients with an artificial airway is needed.

OBJECTIVES

The objective of this study was to develop the Communication with an Artificial airway Tool (CAT) and to test the feasibility and to preliminary evaluate the clinical metrics of the tool.

METHODS

Eligible patients with an artificial airway in the Intensive Care Unit were enrolled in the pilot study (Crit-CAT). The CAT was administered at least twice before and after the communication intervention. Item correlation analysis was performed. Participant and family member acceptability ratings and feedback were solicited. A qualitative thematic analysis was undertaken.

RESULTS

Fifteen patients with a mean age of 53 years (standard deviation [SD]: 19.26) were included. The clinician-reported scale was administered on 50 attempts (100%) with a mean completion time of 4.5 (SD: 0.77) minutes. The patient-reported scale was administered on 46 out of 49 attempts (94%) and took a mean of 1.5 (SD: 0.39) minutes to complete. The CAT was feasible for use in the Intensive Care Unit, with patients with either an endotracheal or tracheostomy tube, whilst receiving invasive mechanical ventilation or not, and while using either verbal or nonverbal modes of communication. Preliminary establishment of responsiveness, validity, and reliability was made. The tool was acceptable to participants and their family members.

CONCLUSION

The clinician-reported and patient-reported components of the study were feasible for use. The CAT has the potential to enable quantifiable comparison of communication interventions for patients with an artificial airway. Future research is required to determine external validity and reliability.

Communicating with mechanically ventilated patients who are awake. A qualitative study on the experience of critical care nurses in Cyprus during the COVID-19 pandemic

BACKGROUND

Modern protocols for light sedation in combination with the increased number of COVID-19 infected patients hospitalized in Intensive Care Units (ICUs) have increased the number of patients who are mechanically ventilated and awake. Nurses require specific skills to care for this vulnerable group of patients. At the same time, nurses report feeling inadequate and frustrated when they attempt to establish communication with mechanically ventilated, conscious patients.

STUDY OBJECTIVES

The purpose of this study was to explore the strategies nurses use when taking care of conscious, intubated patients in the intensive care unit and the barriers they encounter in their effort to communicate.

METHODS

For this study, a qualitative design was employed. Data were collected using in-depth semi-structured interviews with 14 intensive care nurses working at ICUs in four different hospitals of Cyprus. The data were analyzed by applying thematic analysis.

RESULTS

We identified several strategies of unaided (movements-lips, hands, legs-facial expressions, gestures, touching) and aided forms of communication (pen and paper, boards, tablets, mobiles) used by nurses to communicate with patients. However, barriers to communication were reported by the participating nurses mainly pertaining to patients and nurses' characteristics as well as the ICU environment. The health protocols imposed by the pandemic added more obstacles to the communication between nurses and patients mostly related to the use of protective health equipment.

CONCLUSIONS

The results of this study point to the difficulties nurses in Cyprus face when trying to communicate with conscious patients during mechanical ventilation. It appears that the lack of nurses' training and of appropriate equipment to facilitate augmentative and alternative communication leave the complex communication needs of critically ill patients unaddressed. However, further research including patients' opinions, after they recover, would bring more clarity on this topic. Our study adds evidence to the communication crisis created by the protective health protocols imposed by the pandemic. As such, it highlights the need to educate nurses in augmentative and alternative ways of communication to address communication with mechanically ventilated, conscious patients during their ICU stay.

Development and pilot implementation of a patient-oriented discharge summary for critically Ill patients

BACKGROUND

Patients leaving the intensive care unit (ICU) often experience gaps in care due to deficiencies in discharge communication, leaving them vulnerable to increased stress, adverse events, readmission to ICU, and death. To facilitate discharge communication, written summaries have been implemented to provide patients and their families with information on medications, activity and diet restrictions, follow-up appointments, symptoms to expect, and who to call if there are questions. While written discharge summaries for patients and their families are utilized frequently in surgical, rehabilitation, and pediatric settings, few have been utilized in ICU settings.

AIM

To develop an ICU specific patient-oriented discharge summary tool (PODS-ICU), and pilot test the tool to determine acceptability and feasibility.

METHODS

Patient-partners (i.e., individuals with lived experience as an ICU patient or family member of an ICU patient), ICU clinicians (i.e., physicians, nurses), and researchers met to discuss ICU patients' specific informational needs and design the PODS-ICU through several cycles of discussion and iterative revisions. Research team nurses piloted the PODS-ICU with patient and family participants in two ICUs in Calgary, Canada. Follow-up surveys on the PODS-ICU and its impact on discharge were administered to patients, family participants, and ICU nurses.

RESULTS

Most participants felt that their discharge from the ICU was good or better (n = 13; 87.0%), and some (n = 9; 60.0%) participants reported a good understanding of why the patient was in ICU. Most participants (n = 12; 80.0%) reported that they understood ICU events and impacts on the patient's health. While many patients and family participants indicated the PODS-ICU was informative and useful, ICU nurses reported that the PODS-ICU was "not reasonable" in their daily clinical workflow due to "time constraint".

CONCLUSION

The PODS-ICU tool provides patients and their families with essential information as they discharge from the ICU. This tool has the potential to engage and empower patients and their families in ensuring continuity of care beyond ICU discharge. However, the PODS-ICU requires pairing with earlier discharge practices and integration with electronic clinical information systems to fit better into the clinical workflow for ICU nurses. Further refinement and testing of the PODS-ICU tool in diverse critical care settings is needed to better assess its feasibility and its effects on patient health outcomes.

Breaking Up and a New Beginning When One's Partner Goes into a Nursing Home: An Interview Study

In aging societies worldwide, spouses take on great responsibility for care when their partner continues to live at home. Nursing home placement occurs when the partner becomes too frail due to multimorbidity, and this will cause a change in the spouse’s life. This study aimed to explore the spouse’s experience of their partner’s move to a nursing home. Two interviews were conducted at 9-month intervals within the project entitled “Implementation of Knowledge-Based Palliative Care in Nursing Homes”. Thirteen spouses from both urban and rural areas were included, with an age-range of 60–86 years (median 72). Qualitative content analysis was performed. The main findings were captured in two themes: Breaking up of close coexistence and Towards a new form of daily life. The first encompassed processing loneliness, separation and grief, exhaustion, increased burden, and a sense of guilt. The second encompassed a sense of freedom, relief, acceptance, support and comfort. Professionals in both home care and nursing home care need to develop and provide a support programme conveying knowledge of the transition process to prevent poor quality of life and depression among the spouses. Such a programme should be adaptable to individual needs and should ideally be drawn up in consultation with both partners.

Patients' memories from intensive care unit: A qualitative systematic review

AIM

To identify and synthesize the evidence regarding adult patients' memories from their stay in the intensive care unit.

DESIGN

A qualitative systematic review and meta-synthesis. PROSPERO # CRD42020164928. The review employed the guideline of Bettany-Saltikov and McSherry and the Enhancing transparency in reporting the synthesis of qualitative research guidelines.

METHODS

Systematic search for qualitative studies published between January 2000 and December 2019 in Cumulative Index to Nursing and Allied Health, Medical Literature Analysis and Retrieval System Online, PsycINFO, and Excerpta Medica Database. Pairs of authors independently assessed eligibility, appraised methodological quality using Joanna Briggs's quality appraisal tool and extracted data. The analysis followed the principles of interpretative synthesis.

RESULTS

Sixteen papers from 15 studies were included in the review. Three themes emerged: (a) memories of surreal dreams and delusions, (b) care memories from sanctuary to alienation and (c) memories of being vulnerable and close to death.

Survivors of Critical Illness and Their Relatives. A Qualitative Study on Hospital Discharge Experience

Rationale: To target rehabilitation needs of survivors of critical illness and their relatives in a timely and adequate manner, a thorough needs assessment is recommended when hospital discharge planning is initiated. In light of existing evidence on physical and psychological consequences of critical illness for patients and family, it is currently unclear if current hospital discharge procedures suffice to meet the needs of this group.Objectives: To explore hospital discharge experience and to identify perceived barriers and enablers for a positive transition experience from hospital to home or rehabilitation facility as perceived by survivors of critical illness and their families.Methods: We performed a grounded theory study with semi-structured interviews among a group of survivors of critical illness and their relatives (n = 35) discharged from 16 hospitals across the Netherlands. Interviews were audio recorded and transcribed verbatim. Using constant comparative methods, initial and focused coding was applied to the data, which were further labeled into major categories and subcategories, ultimately leading to the identification of key concepts. Triangulation was applied through several reflexivity meetings at different stages of the study.Results: Twenty-two former intensive care unit patients and 13 relatives were interviewed. The mean age was 53 (standard deviation ± 11.2) and 60% were female. Median intensive care unit and hospital length of stay were 14 days (interquartile range, 9.75-24.5) and 35 days (interquartile range, 21.75-57.25), respectively. Thematic analyses led to identification of seven key concepts, representing barriers and enablers to a positive transition experience. "Existing in a fragmented reality," "being overlooked," and "feeling disqualified" were identified barriers and "feeling empowered," "encountering empathic and expert professionals," "managing recovery expectations," and "family engagement" were identified as enablers for a positive perceived transition experience.Conclusions: Findings of this study suggest that current hospital discharge practice for survivors of critical illness is driven by speed and efficiency, rather than by individual needs assessments, despite advocacies for patient- and family-centered care. Discharge strategies should be customized to facilitate adequate and comprehensive assessment of aftercare needs, conducted at the right time and within the right context, encouraging empowerment and a positive perceived transition from hospital to home.

Could therapeutic diaries support recovery in psychiatric intensive care?

Despite growing literature surrounding the use of patient diaries in intensive care units within general health care and the positive effects these may have on a patient's psychological recovery from such an admission, no studies exist examining the effects of similar patient diaries in psychiatric intensive care units when used with people experiencing an acute exacerbation of psychosis. This article hypothesises the potential positive effects of diaries kept for patients in psychiatric intensive care units. In the development of strategies to help people in psychiatric crisis understand and manage their own distress and psychological trauma, diaries may be helpful for the prevention of further psychological problems and aid recovery post discharge. Research is required to consider the possible effects of therapeutic diaries and the role of the multidisciplinary team in keeping these within psychiatric intensive care settings.

Patients' experiences of acute deterioration: A scoping review

BACKGROUND

Patient experience is recognised as a means of assessing healthcare delivery with organisations in many countries now gathering patient experience or satisfaction data. It is well documented that the benefits of improving a patients' experience include increased satisfaction, reduced length of stay, improved patient outcomes and reduction of costs. The experience of acute clinical deterioration is unique, extensive and complex as well as being a difficult experience for all involved. However, little is known about this experience from the patient's perspective.

AIM

To explore what is known about the experiences of acute deterioration from the perspective of the patient.

DESIGN

A scoping review of international, peer-reviewed research studies and grey literature published between the years of 2000 and 2018. This review was guided by the three-step search strategy recommended by the Joanna Briggs Institute (JBI).

DATA SOURCES

A range of databases were searched, including CINAHL, Medline, Health Source, Joanna Briggs Institute, PsycINFO, Embase via Ovid, Cochrane library, Ovid Emcare, Scopus as well as grey literature, reference lists and the search engine Google Scholar.

REVIEW METHODS

Joanna Briggs Institute (JBI) scoping review framework was utilised to identify patients' experiences of acute deterioration. Ten databases were searched, and 249 articles were retrieved. After screening the titles and abstracts, 102 articles were assessed in full text for eligibility, and finally 23 articles were further analysed and synthesised using inductive thematic analysis.

RESULTS

19 qualitative studies, three quantitative and one mixed methods study met the inclusion criteria. Seven key themes emerged related to patients' experience of acute deterioration: (1) transformation of perception: memories of factual events; (2) psychological transformation: emotional distress and well-being; (3) physiological transformation: physical distress; (4) facing death; (5) the severity of acute deterioration: from the perspective of the patient; (6) relationship with healthcare professionals and the clinical environment; and (7) the value of relationships: the support of family and friends.

CONCLUSIONS

Participants had considerable recall of their experiences and hospital admissions. The themes highlight the important issues patients face during their own acute physiological deterioration. This review has highlighted that further research is needed to specifically explore the patients' experience of acute deterioration and the emergency management they receive, for example from a hospital's rapid response team (RRT) or medical emergency team (MET).

Identifying patients' support needs following critical illness: a scoping review of the qualitative literature

BACKGROUND

Intensive care survivors suffer chronic and potentially life-changing physical, psychosocial and cognitive sequelae, and supporting recovery is an international priority. As survivors' transition from the intensive care unit to home, their support needs develop and change.

METHODS

In this scoping review, we categorised patients' support needs using House's Social Support Needs framework (informational, emotional, instrumental, appraisal) and mapped these against the Timing it Right framework reflecting the patient's transition from intensive care (event/diagnosis) to ward (stabilisation/preparation) and discharge home (implementation/adaptation). We searched electronic databases from 2000 to 2017 for qualitative research studies reporting adult critical care survivors' experiences of care. Two reviewers independently screened, extracted and coded data. Data were analysed using a thematic framework approach.

RESULTS

From 3035 references, we included 32 studies involving 702 patients. Studies were conducted in UK and Europe (n = 17, 53%), Canada and the USA (n = 6, 19%), Australasia (n = 6, 19%), Hong Kong (n = 1, 3%), Jordan (n = 1, 3%) and multi-country (n = 1, 3%). Across the recovery trajectory, informational, emotional, instrumental, appraisal and spiritual support needs were evident, and the nature and intensity of need differed when mapped against the Timing it Right framework. Informational needs changed from needing basic facts about admission, to detail about progress and treatments and coping with long-term sequelae. The nature of emotional needs changed from needing to cope with confusion, anxiety and comfort, to a need for security and family presence, coping with flashbacks, and needing counselling and community support. Early instrumental needs ranged from managing sleep, fatigue, pain and needing nursing care and transitioned to needing physical and cognitive ability support, strength training and personal hygiene; and at home, regaining independence, strength and return to work. Appraisal needs related to obtaining feedback on progress, and after discharge, needing reassurance from others who had been through the ICU experience.

CONCLUSIONS

This review is the first to identify the change in social support needs among intensive care survivors as they transition from intensive care to the home environment. An understanding of needs at different transition periods would help inform health service provision and support for survivors.

Quality of life improves for tracheostomy patients with return of voice: A mixed methods evaluation of the patient experience across the care continuum

OBJECTIVES

A tracheostomy tube can profoundly impact ability to communicate. The impact of this on patients' self-esteem and quality of life in the care continuum from the intensive care unit to after decannulation has not been reported. Therefore, the aim was to investigate the patient-reported experience regarding change in communication function, communication-related self-esteem and quality of life.

RESEARCH DESIGN

A mixed methods approach was utilised. Quantitative data were obtained using validated measures of self-esteem related to communication-related quality of life and general health. Data were measured before return of voice, within 48 hours of voice return and six months after tracheostomy decannulation. Qualitative data were collected through structured interviews six months after tracheostomy.

RESULTS

Seventeen participants completed the study. Four themes emerged from the interviews: It's hard communicating without a voice; What is happening to me?; A storm of dark emotions and More than a response…it's participating and recovering. Significant positive change occurred in six items of self-esteem related to communication from baseline to return of voice. Overall, positive changes in quality of life scores were observed.

CONCLUSIONS

Voice loss with tracheostomy significantly affected participants' abilities to effectively communicate their care and comfort needs. Restoration of voice occurred in conjunction with patient-reported improved mood, outlook and sense of recovery.

Critical illness trajectory for patients, families and nurses - a literature review

BACKGROUND

In the 21st century, we are starting to discover and understand the longer term sequelae of critical illness from both patient's and family members' perspectives. The consequential effects on physical and psychological function and the social landscape are being slowing realized. We are beginning to understand the long-term legacy of critical care, with survivorship possibly the greatest challenge within the critical care setting.

AIM

To draw together research that has appraised the experience of surviving critical illness from the holistic, triadic perspectives of survivor, relative and critical care nurse. In doing so, knowledge of the complexities of the critical care trajectory is enhanced.

SEARCH STRATEGY

Using Medline; Assia; CINAHL Plus; SCOPUS; Web of knowledge searches from 2000 to 2015 were conducted utilizing the terms 'critical care'; 'intensive care', ITU; patient*; relative*; family member*; experience*; nurse*, and trajectory. Relevant exclusion criteria were applied to provide a generalist adult critical care perspective.

RESULTS

Following a process of constant comparative analysis of the literature and thematic synthesis, seven themes were highlighted. Facing mortality, critical junctures, physiological sequelae, psychological sequelae, family presence, beyond meeting the needs of family members and technology versus humanity were all emergent themes.

CONCLUSION

As humans, we do not live an isolated life; we are interdependent upon each other. This inclusive review of literature has highlighted the lacunae and areas of dissonance both in the literature and in clinical practice in relation to the critical care trajectory as experienced by survivors of critical illness and their families.

RELEVANCE TO CLINICAL PRACTICE

Critical care nurses can and should play a role in preparing and supporting patients and families beyond the critical care unit. In turn, Registered Nurses needed to be supported to fulfil this important role in enabling the process of moving patients and their families from surviving to thriving (survivorship).

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 experience of communication difficulties in critically ill patients in and beyond intensive care: Findings from a larger phenomenological study

Communication difficulties in intensive care units (ICU) with critically ill patients have been well documented for more than three decades. However, there is only a paucity of literature that has explored communication difficulties beyond the ICU environment. This paper discusses the experience of communication difficulties in critically ill patients in ICU and beyond as part of findings from a larger study that explored the lived experiences of critically ill patients in ICU in the context of daily sedation interruption (DSI). The aim of the study was to describe the lived experience of people who experienced critical illness in ICU using a hermeneutic phenomenological approach in the DSI context. Twelve participants aged between 20 and 76 years with an ICU stay ranging from 3 to 36 days were recruited from a 16 bed ICU in a large regional referral hospital in New South Wales (NSW), Australia. Participants were intubated, mechanically ventilated and subjected to (DSI) during their critical illness in ICU. In-depth face to face interviews with participants were conducted at two weeks after discharge from ICU and at six to eleven months later. Interviews were audio taped and transcribed. Thematic analysis using van Manen's (1990) method was completed. The overarching theme; 'Being in limbo' and subthemes 'Being disrupted'; 'Being imprisoned' and 'Being trapped' depict the main elements of the experience. This paper discusses communication difficulties in critically ill patients as one of the main findings relating to the theme 'Being trapped'. Participants' reports of communication difficulties in ICU are similar to those reported by patients in other studies where DSI was not used. However, not many studies have reported ongoing communication difficulties after ICU hospitalisation. Recommendations are made for new models of care and support to mitigate critically ill patients' communication concerns in ICU and for further research into the causes and treatment to benefit this group of patients. Most importantly, extra care is recommended not to damage vocal cords during intubation and cuff inflation in the course of mechanical ventilation.

Jordanian survivors' experiences of recovery from critical illness: a qualitative study

BACKGROUND

Despite the fact that a lot of patients consider their discharge from hospitals as a positive sign of progress towards regained health, many of them start suffering from physical, psychological and social problems after discharge from intensive care units.

AIM

This study aims to describe the experiences of Jordanian survivors of critical illnesses 3 months after discharge from a hospital intensive care unit.

METHODS

A descriptive qualitative approach was used to involve 18 Jordanian patients from two hospitals in a major Jordanian city using open-ended interviews. Interview transcripts were analysed using content analysis method.

RESULTS

Three main themes have emerged from the data: (1) new meaning of life; (2) different perspectives on the meaning of life, and (3) struggle for role identity.

LIMITATION

The sample was chosen from one city in Jordan; longitudinal study might help identify the change in patients' experiences over time.

CONCLUSION

Patients described the discharge from the intensive care unit as a means of rescue from death; they began to value their spiritual and religious rituals. Negative traumatic experiences hindered the patients' recovery process. During recovery, patients struggled to resume their power and role in family.

IMPLICATIONS FOR NURSES AND HEALTH POLICY

This study emphasizes the importance of providing care according to the patient's individual needs, related to their cultural and spiritual milieu; there is a need to develop follow-up services for ICU survivors within a national health policy. Further educational and training programmes in the patient's issues after discharge from hospital are needed. This will definitely help nurses care after this patient group.

Does an additional structured information program during the intensive care unit stay reduce anxiety in ICU patients?: a multicenter randomized controlled trial

BACKGROUND

Communication and information in order to reduce anxiety in the intensive care unit (ICU) has been described as area needing improvement. Therefore, the aim of this trial was to evaluate whether a structured information program that intensifies information given in standard care process reduces anxiety in ICU patients.

METHODS

Multicenter, two-armed, non-blinded, parallel-group randomized controlled trial in hospitals in the cities of Marburg, Halle, and Stuttgart (Germany). The trial was performed in cardiac surgery, general surgery, and internal medicine ICUs. Two-hundred and eleven elective and non-elective ICU patients were enrolled in the study (intervention group, n = 104; control group, n = 107). The experimental intervention comprised a single episode of structured oral information that was given in addition to standard care and covered two main parts: (1) A more standardized part about predefined ICU specific aspects - mainly procedural, sensory and coping information, and (2) an individualized part about fears and questions of the patient. The control group received a non-specific episodic conversation of similar length additional to standard care. Both conversations took place at the beginning of the ICU stay and lasted 10-15 minutes. Study nurses administered both interventions. The primary outcome ICU-related anxiety (CINT-Score, 0-100 pts., higher scores indicate higher anxiety) was assessed after admission to a regular ward.

RESULTS

The primary outcome could be measured in 82 intervention group participants and 90 control group participants resulting in mean values of 20.4 (SD 14.4) compared to 20.8 (SD 14.7) and a mean difference of -0.2 (CI 95% -4.5 to 4.1).

CONCLUSIONS

A structured information intervention additional to standard care during ICU stay had no demonstrated additional benefit compared to an unspecific communication of similar duration. Reduction of anxiety in ICU patients will probably require more continuous approaches to information giving and communication.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00764933.

Providing critical care patients with a personalised discharge summary: a questionnaire survey and retrospective analysis exploring feasibility and effectiveness

OBJECTIVES

This paper reports on the potential value and feasibility of providing patients with a personalised discharge summary of their critical care stay.

DESIGN AND METHODS

Fifty-one patient discharge summaries, written by nurses during a randomised controlled trial, were retrospectively analysed for readability, structure and quality. A questionnaire survey completed by trial patients (n=42), their relatives (n=21) and nurses (n=170) explored user experience and feasibility. Quantitative questionnaire data were analysed descriptively and inferentially; qualitative data were subjected to content analysis.

RESULTS

Most completed summaries achieved at least an average readability score and were of an acceptable quality. Motivation, time constraints and competing priorities were identified as key barriers to writing an effective summary; however, in the majority of cases, writing them had taken less than 15 minutes. Questionnaire data support that patient discharge summaries can help patients, relatives and ward nurses better understand and patients accept, what happened in critical care.

CONCLUSION

Patient discharge summaries are likely to be a useful adjunct to existing discharge information, but further work is required to determine when and how they should be provided. With appropriate training and support, it is feasible for nurses to write discharge summaries in a busy critical care environment.

Experiences of inner strength in critically ill patients--a hermeneutical approach

Becoming critically ill and in need of ventilator treatment is a considerable burden. Fear and anxiety are natural reactions and it is not uncommon for patients to experience hopelessness, withdrawal and depression. In situations like these the possession of inner strength can be of vital importance.

OBJECTIVES

To gain knowledge on what factors contribute to inner strength in critically ill patients cared for in an intensive care unit. The depth interviews were conducted with six former ventilator-treated patients aged 60-72years.

SETTING

The informants were recruited through the ICU at an urban hospital in Norway.

RESEARCH METHODOLOGY/DESIGN

The study has an exploratory and descriptive design. A hermeneutic approach was used to interpret the data, in which Kvale's self-perception, critical common sense and theoretical levels were applied.

RESULTS

The study clearly demonstrates that there are certain factors that promote the inner strength of patients undergoing ventilator treatment. These are: "To have the support of next of kin", "The wish to go on living", "To be seen" and "Signs of progress". Amongst these patients it appears that the presence of one's next of kin has prime significance in promoting inner strength.

Unpleasant and pleasant memories of intensive care in adult mechanically ventilated patients--findings from 250 interviews

AIM

In order to improve the patients' comfort and well-being during and after a stay in the intensive care unit (ICU), the patients' perspective on the intensive care experience in terms of memories is essential. The aim of this study was to describe unpleasant and pleasant memories of the ICU stay in adult mechanically ventilated patients.

METHOD

Mechanically ventilated adults admitted for more than 24hours from two Swedish general ICUs were included and interviewed 5 days after ICU discharge using two open-ended questions. The data were analysed exploring the manifest content.

FINDINGS

Of the 250 patients interviewed, 81% remembered the ICU stay, 71% described unpleasant memories and 59% pleasant. Ten categories emerged from the content analyses (five from unpleasant and five from pleasant memories), contrasting with each other: physical distress and relief of physical distress, emotional distress and emotional well-being, perceptual distress and perceptual well-being, environmental distress and environmental comfort, and stress-inducing care and caring service.

CONCLUSION

Most critical care patients have both unpleasant and pleasant memories of their ICU stay. Pleasant memories such as support and caring service are important to relief the stress and may balance the impact of the distressing memories of the ICU stay.

Critical care nurses' experiences of follow-up visits to an ICU

AIM

The aim of this study was to describe critical care nurses' experiences of follow-up visits for formerly critically ill people discharged from an intensive care unit and their close relatives.

BACKGROUND

The critical illness experience affects the ill person and their close relatives not only during the stay in an intensive care unit, but also for a long time afterwards. Follow-up visits were introduced to offer people the opportunity to talk about their experiences. This activity has not been studied earlier from the perspective of critical care nurses.

DESIGN

The design of this study was qualitative.

METHOD

Eight critical care nurses narrated their experiences of follow-up visits by formerly critically ill people and their close relatives to an intensive care unit. Data were collected during 2007-2008. Qualitative thematic content analysis was applied to the interview texts.

RESULTS

The findings show that to feel they were doing a good job it was vital for the critical care nurses to be well prepared for the follow-up visits. It was difficult, in a positive way, to recognise formerly critically ill people when they returned looking healthy. The critical care nurses were disappointed that their former patients remembered so few real events. The follow-up visits gave the critical care nurses a new picture of how the critically illness experience influenced the former patient's everyday life during and after their stay in the intensive care unit and how it affected the lives of their close relatives.

CONCLUSIONS

Through sharing the experiences of formerly critically ill peoples' and their close relatives' critical care nurses receive valuable feedback about their work.

RELEVANCE TO CLINICAL PRACTICE

Receiving feedback about one's work from follow-up visits gives critical care nurses the possibility for to evaluate given care. Follow-up visits to intensive care units can provide them with valuable knowledge that might lead to improved nursing care.

Experiences of intensive care unit diaries: 'touching a tender wound'

AIM

The aim of this study was to describe peoples' experiences of a personal diary written when they were critically ill and receiving care in an intensive care unit (ICU).

BACKGROUND

In some ICUs, diaries are written by the ICU staff and close relatives of those who are critically ill and mechanically ventilated, but there is a lack of studies that focus on the experiences of the formerly critically ill of personal diaries written when in an ICU.

METHODS

Qualitative personal interviews were conducted with nine people who were formerly critically ill. The interview texts were analysed using qualitative content analysis.

FINDINGS

From the analysis of the data, one theme emerged - touching a tender wound, with four categories: being afraid and being deeply touched, appreciating close relatives' notes, a feeling of unreality and gaining coherence. The participants were deeply touched when they read the diary for the first time. Parts of it were experienced as unreal, as if they were reading about someone else. The diary provided necessary knowledge about what had happened during the time when the participants were critically ill and from which they had only fragmented or no memories at all. Even though it aroused strong feelings, reading the diary was experienced as an important support for a long time after their stay in the ICU. Experiencing that one was not fully aware of what had happened and then reading about oneself being critically ill and about one's close relatives' experiences was interpreted as touching a tender wound.

CONCLUSIONS AND RELEVANCE TO CLINICAL PRACTICE

It is suggested that a diary may be a tool that can help formerly critically ill people to gain a sense of coherence concerning their critical illness experience, but reading it can be painful and demanding.