Analysis of patient diaries in Danish ICUs: A narrative approach

Effects of ICU diaries on psychological disorders and sleep quality in critically ill patients and their family members: A systematic review and meta-analysis

BACKGROUND

The psychological health and sleep quality of intensive care unit (ICU) patients and their families have health implications, and greater attention should be devoted to developing effective interventions to address these concerns. Due to an increasing amount of evidence on ICU diary interventions, their comparative effectiveness should be evaluated.

AIMS

This systematic review and meta-analysis aimed to evaluate the effect of ICU diaries on psychological disorders and sleep quality in critically ill patients and on psychological disorders in their family members.

METHODS

The PubMed, Embase, Web of Science, Cochrane Library, China Biomedical Literature Database, China National Knowledge Network, Wanfang Database, and Weipu Chinese Journal databases were searched up to November 2023 to identify randomized controlled trials. We used the Cochrane Risk of Bias Tool for quality assessment, and we used Review Manager 5.4 software to conduct meta-analysis.

RESULTS

Eleven studies with a total of 1682 patients met the inclusion criteria.

PATIENTS

PTSD (7 studies, 1015 patients): OR 0.63 (95%CI 0.45-0.87), p = 0.005; Anxiety (6 studies, 546 patients): OR 0.52 (95%CI 0.22-1.27), p = 0.15; Depression (6 studies, 546 patients): OR 0.62 (95%CI 0.39-0.97), p = 0.04; sleep quality (2 studies, 203 patients): OR -3.97 (95%CI -7.71-0.23), p = 0.04. Family members: PTSD (2 studies, 652 patients): OR 0.81 (95%CI 0.37-1.79), p = 0.60; Anxiety (2 studies, 650 family members): OR 1.09 (95%CI 0.79-1.49), p = 0.62; Depression (2 studies, 650 patients): OR 1.03 (95%CI 0.71-1.50), p = 0.87. The pooled results of the meta-analysis showed that ICU diaries reduced the incidence of depression and post-traumatic stress disorder and improved sleep quality in patients, but had no significant effects on patients' anxiety status or family members' psychological disorders. Three of the included studies had a high quality, and the remaining eight studies had a moderate quality.

CONCLUSIONS

For patients, ICU diaries can improve their depression and post-traumatic stress disorder, improve sleep quality, but has no significant effect on anxiety; For family members, ICU diaries were not significant. Due to the existence of bias and the limited sample size, the results should be interpreted with caution. Researchers need to further elucidate the multidisciplinary collaborative process of diary-based treatment in ICUs and its impact on psychological disorders in family members. Furthermore, large-scale, multicentre, robust studies should be conducted in the future.

Patients' lived body experiences in the intensive care unit and beyond - a meta-ethnographic synthesis

INTRODUCTION

Physical therapists supporting patients in intensive care unit (ICU) rehabilitation can improve their clinical practice with insight in patients' lived body experiences.

OBJECTIVE

To gain insight in patients' lived body experiences during ICU stay and in recovery from critical illness.

METHODS

Through a comprehensive systematic literature search, 45 empirical phenomenological studies were identified. Patients' lived body experiences were extracted from these studies and synthesized following the seven-phase interpretative approach as described by Noblit and Hare.

RESULTS

Three lines of argument were illuminated: 1) "recovery from critical illness starts from a situation in which patients experience the lived body as unable;" 2) "patients experience progress in recovery from critical illness when the lived body is empowered;" and 3) "recovery from critical illness results in a lived body changed for life." Eleven third-order constructs were formulated as different kinds of bodies: 1) "an intolerable body;" 2) "an alienated body;" 3) "a powerless body;" 4) "a dependent body;" 5) "a restricted body;" 6) "a muted body;" 7) "a touched body;" 8) "a transforming body;" 9) "a re-discovering body;" 10) "an unhomelike body;" and 11) "a remembering body."

CONCLUSION

Patients' lived body experiences during ICU stay and in recovery from critical illness have richly been described in phenomenological studies and were synthesized in this meta-ethnography.

Enhancing family experience in the paediatric intensive care unit through the adoption of the family care journal: A single-center study

BACKGROUND

Multidisciplinary patient care rounds are increasingly seen as a vital complement to patient care management. Family engagement in these rounds, especially in the paediatric population, is important to treatment and outcomes, but there is little information about family experience in the Paediatric Intensive Care Unit (PICU).

AIMS

To develop a process using family care journals (FCJ) to systematically evaluate family experience in the PICU and identify needed supportive resources that will enhance their critical care stay.

STUDY DESIGN

This is a single-centre quasi-experimental design conducted at a large urban quaternary level freestanding children's hospital. A family care journal (FCJ) was distributed to families upon admission to PICU to serve as a resource tool during their stay. An electronic point of care (POC) questionnaire was used to assess families' experiences in the PICU.

RESULTS

Three hundred sixty-six questionnaires were completed (100% response rate) and analysed. Overall, there was an improvement in all phases post FCJ implementation compared with the baseline. Seventy five percent of families found it a useful tool for communication with the PICU team. Open-ended comments revealed improvement opportunities related to communication, environment, and delay in care. Almost all commented on excellent nursing care.

CONCLUSIONS

Introducing FCJ in a paediatric ICU is a practical approach, providing a cost-effective method to assess family experiences and gain insights for ongoing quality improvement efforts. Collaboration among all care team members, including nursing, medical, and administrative leaders, is crucial for empathetically addressing parental needs during hospitalization.

RELEVANCE TO CLINICAL PRACTICE

Combining the use of journals and questionnaires provides the clinical team with an efficient means of collecting valuable feedback from parents regarding their experience in the PICU and the factors that foster ongoing commitment from families. Nurses play a crucial role in encouraging the adoption of these journals, as they promote greater parent involvement in their children's care.

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.

Finding the right words: A focus group investigation of nurses' experiences of writing diaries for intensive care patients with a poor prognosis

BACKGROUND

The overall purpose of diaries written during an intensive care stay is to help patients fill in memory gaps from the illness trajectory, which might promote long-term psychological recovery. Diaries have also been shown to benefit nurses in maintaining a view of the patient as a person in the highly technical environment and to promote reflection. There is a lack of research on how nurses might be affected by writing a diary for critically ill patients with a poor prognosis.

OBJECTIVES

The aim of this study was to investigate nurses' experience of writing diaries for intensive care patients with a poor prognosis.

METHODS

This study has a qualitative descriptive design and was inspired by the methodology of interpretive description. Twenty-three nurses from three Norwegian hospitals with a well-established practice of writing diaries participated in four focus groups. Reflexive thematic analysis was used. The study was reported according to the Consolidated Criteria for Reporting Qualitative Research checklist.

FINDINGS

The overarching theme resulting from our analysis was "Finding the right words". This theme represents the challenge of writing in view of the uncertainty of the patient's survival and of who would read the diary. It was important to strike the right tone with these uncertainties in mind. When the patient's life could not be saved, the purpose of the diary expanded to comforting the family. To put an extra effort into making the diary something special when the patient was dying was also a meaningful activity for the nurses.

CONCLUSIONS

Diaries may serve other purposes than helping patients to understand their critical illness trajectory. In cases of a poor prognosis, nurses adapted their writing to comfort the family rather than informing the patient. Diary writing was meaningful for the nurses in managing care of the dying patient.

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

OBJECTIVE

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

DESIGN

Qualitative study.

SETTING

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

METHODS

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

FINDINGS

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

CONCLUSION

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

IMPLICATIONS FOR CLINICAL PRACTICE

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

Use of narrative methods in rehabilitation and palliative care in Scandinavian countries: A scoping review

BACKGROUND

Although narratives-including an ill person's life story, life situation and future perspectives-seem to lie at the core of rehabilitation and palliative care in Scandinavian countries, we lack a scope of how, when and where narrative methods are used. Such a scope could provide knowledge and inspiration on a practical as well as a policy level. The objective of this study is to explore the literature on the use of systematic, narrative methods in rehabilitative and palliative care for people with life-threatening illness in Scandinavian countries.

METHOD

We conducted a scoping review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) where applicable. We performed a systematic search in CINAHL, Medline, PsychInfo, SOCIndex and SveMed+using the search terms 'life threatening illness', 'narratives', 'rehabilitation', 'palliative care' and 'Scandinavia', followed by a search for grey literature. We found 42 records to be eligible for this scope and extracted the data via piloted extraction tables.

RESULTS

We identified 17 narrative methods and present findings concerning four themes: (1) a record of the narrative methods used; (2) an objective and theoretical framework for the narrative methods; (3) the content and form of the narrative methods; and (4) the significance of the narrative methods used.

CONCLUSION

Narrative methods are used in systematic ways in rehabilitation and palliative care in Scandinavian countries and cover a wide variety of objectives, theoretical frames, forms and outcomes. Further development may benefit from more elaboration on definitions and the relationships between objectives, theoretical frameworks and outcomes.

Evaluating the Feasibility and Efficacy of a Pediatric Intensive Care Unit Diary

As the progress of critical care medicine has improved the survival rate of critically ill patients, comorbidities and long-term health care have attracted people's attention. The terms "post-intensive care syndrome" (PICS) and "PICS-family" (PICS-F) have been used in non-neurocritical care populations, which are characterized by the cognitive, psychiatric, and physical sequelae associated with intensive care hospitalization of survivors and their families. An intensive care unit (ICU) diary authored by the patient's family members may alleviate the psychological distress of the patient and his or her family. This quality improvement project focused on the development and implementation of the pediatric intensive care unit (PICU) diary in the pediatric critical care setting. The project aims to evaluate the feasibility and the potential efficacy of the PICU diary, measured through parental acceptance and satisfaction. Seventeen families of critically ill children admitted to the PICU received the PICU diary during the implementation period. Twenty-four parents completed the weekly follow-up, and 15 subsequently completed the diary entry evaluation. The use of the diary in the PICU setting is feasible and considered beneficial by families of critically ill children.

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.

Approaches to Addressing Post-Intensive Care Syndrome among Intensive Care Unit Survivors. A Narrative Review

Critical illness can be lethal and devastating to survivors. Improvements in acute care have increased the number of intensive care unit (ICU) survivors. These survivors confront a range of new or worsened health states that collectively are commonly denominated post-intensive care syndrome (PICS). These problems include physical, cognitive, psychological, and existential aspects, among others. Burgeoning interest in improving long-term outcomes for ICU survivors has driven an array of potential interventions to improve outcomes associated with PICS. To date, the most promising interventions appear to relate to very early physical rehabilitation. Late interventions within aftercare and recovery clinics have yielded mixed results, although experience in heart failure programs suggests the possibility that very early case management interventions may help improve intermediate-term outcomes, including mortality and hospital readmission. Predictive models have tended to underperform, complicating study design and clinical referral. The complexity of the health states associated with PICS suggests that careful and rigorous evaluation of multidisciplinary, multimodality interventions-tied to the specific conditions of interest-will be required to address these important problems.

Narrative critical care: A literary analysis of first-person critical illness pathographies

BACKGROUND

Life-threatening illness can be devastating for patients as they experience shifting levels of consciousness, recurrent delirium, and repeated setbacks. Narrative Medicine and its sub-discipline Narrative Critical Care increase healthcare professionals' understanding of the patient perspective, and interpretation of their stories is a means to improving practice.

PURPOSE

We aimed to investigate book length first-person accounts of critical illness to gain a deeper understanding of universal and individual patient responses and to provide an example of Narrative Critical Care.

METHOD

We performed a comparative literary analysis of five books supported by the Biographical Narrative Interpretive Method (BNIM) that moves through stages of structural analysis, thematic analysis, and cross-case theoretisation.

FINDINGS

Universal patient responses evolved through five existential dichotomies of life/death, sanity/madness, before/after, gain/loss and inner strength/external support. Individual patient responses were expressed as turning points along the illness trajectory, and biographical continuity was restored by integration of new self and old self.

CONCLUSION

We uncovered commonalities and differences in storied accounts of critical illness and survival. New insights might enable healthcare professionals to personalize patient care. More consistency is needed during transitions and rehabilitation of intensive care survivors.

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.

Review: Post-Intensive Care Syndrome: Unique Challenges in the Neurointensive Care Unit

Within the last couple of decades, advances in critical care medicine have led to increased survival of critically ill patients, as well as the discovery of notable, long-term health challenges in survivors and their loved ones. The terms post-intensive care syndrome (PICS) and PICS-family (PICS-F) have been used in non-neurocritical care populations to characterize the cognitive, psychiatric, and physical sequelae associated with critical care hospitalization in survivors and their informal caregivers (e.g., family and friends who provide unpaid care). In this review, we first summarize the literature on the cognitive, psychiatric, and physical correlates of PICS and PICS-F in non-neurocritical patient populations and draw attention to their long-term negative health consequences. Next, keeping in mind the distinction between disease-related neurocognitive changes and those that are associated directly with the experience of a critical illness, we review the neuropsychological sequelae among patients with common neurocritical illnesses. We acknowledge the clinical factors contributing to the difficulty in studying PICS in the neurocritical care patient population, provide recommendations for future lines of research, and encourage collaboration among critical care physicians in all specialties to facilitate continuity of care and to help elucidate mechanism(s) of PICS and PICS-F in all critical illness survivors. Finally, we discuss the importance of early detection of PICS and PICS-F as an opportunity for multidisciplinary interventions to prevent and treat new neuropsychological deficits in the neurocritical care population.

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

OBJECTIVE

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

DESIGN

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

SETTING

Interviews took place in participants' homes.

FINDINGS

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

CONCLUSION

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

Assessment of patient satisfaction and preferences with an intensive care diary

Objectives

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

Methods

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

Results

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

Conclusions

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

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Structure and content of diaries written by close relatives for intensive care unit patients: A narrative approach (DRIP study)

AIM

To investigate structure and content of a nurse prompted diary written by relatives for intensive care unit (ICU) patients.

DESIGN

A narrative analysis of ICU diaries.

METHODS

From September 2015-August 2016, 12 diaries authored by 12 relatives for 12 ICU patients were sampled at 3-4 months post-ICU discharge. We used Ricoeur's hermeneutical phenomenology as a framework for a narrative analysis of the diaries. The first step was naïve reading, followed by structural analysis exploring the internal relations of the text. The structural analysis was broadened by exploring narrative structures. The last step was critical interpretation of the findings.

FINDINGS

The diaries had a clear narrative structure; the diary-timeline consisted of: Pre-ICU phase, Early ICU phase, Culmination, Recovery and Post-ICU reflection. Three themes described the content of the diary: Struggling to get the story right for the patient; striving to understand what was happening and longing to re-establish a connection with the patient. Keeping a diary was perceived by the relatives as a challenging but rewarding task.

CONCLUSION

The diary had the potential for reflection and a deeper understanding of the ICU stay. The diary served as a locus for patient and relatives to connect or re-connect, but some diaries might be too personal and emotional to share with the patient. Future research needs to explore advantages and disadvantages of ICU diaries authored by relatives.

Feasibility and Perceptions of PICU Diaries

OBJECTIVES

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

DESIGN

Observational pilot study.

SETTING

PICU in a tertiary academic hospital in the United States.

PARTICIPANTS

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

INTERVENTIONS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

Humanization of critical care-psychological effects on healthcare professionals and relatives: a systematic review

PURPOSE

To systematically review and evaluate the effects of humanized care of the critically ill on empathy among healthcare professionals, anxiety among relatives, and burnout and compassion fatigue in both groups.

SOURCE

MEDLINE, PsycINFO, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), and ProQuest Dissertations were searched from inception to 29 June 2017 for studies that investigated the effects of interventions with potential to humanize care of the critically ill on the following outcomes: empathy among critical care professionals, anxiety among relatives, and burnout and compassion fatigue in either group. We defined a humanizing intervention as one with substantial potential to increase physical or emotional proximity to the patient. Two reviewers independently selected studies, extracted data, and assessed risk of bias and data quality.

PRINCIPAL FINDINGS

Twelve studies addressing four discrete interventions (liberal visitation, diaries, family participation in basic care, and witnessed resuscitation) and one mixed intervention were included. Ten studies measured anxiety among 1,055 relatives. Two studies measured burnout in 288 critical care professionals. None addressed empathy or compassion fatigue. Eleven of the included studies had an overall high risk of bias. No pooled estimates of effect were calculated as a priori criteria for data synthesis were not met.

CONCLUSIONS

We found insufficient evidence to make any quantitative assessment of the effect of humanizing interventions on any of these psychologic outcomes. We observed a trend towards reduced anxiety among family members who participated in basic patient care, liberal visitation, and diary keeping. We found conflicting effects of liberal visitation on burnout among healthcare professionals.

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

Background

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

Method

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

Discussion

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

Trial registration

NCT02357680. Registered September 3, 2015.

The ICU-Diary study: prospective, multicenter comparative study of the impact of an ICU diary on the wellbeing of patients and families in French ICUs

BACKGROUND

Post-intensive care syndrome includes the multiple consequences of an intensive care unit (ICU) stay for patients and families. It has become a new challenge for intensivists. Prevention programs have been disappointing, except for ICU diaries, which report the patient's story in the ICU. However, the effectiveness of ICU diaries for patients and families is still controversial, as the interpretation of the results of previous studies was open to criticism hampering an expanded use of the diary. The primary objective of the study is to evaluate the post-traumatic stress syndrome in patients. The secondary objectives are to evaluate the post-traumatic stress syndrome in families, anxiety and depression symptoms in patients and families, and the recollected memories of patients. Endpoints will be evaluated 3 months after ICU discharge or death.

METHODS

A prospective, multicenter, randomized, assessor-blind comparative study of the effect of an ICU diary on patients and families. We will compare two groups: one group with an ICU diary written by staff and family and given to the patient at ICU discharge or to the family in case of death, and a control group without any ICU diary. Each of the 35 participating centers will include 20 patients having at least one family member who will likely visit the patient during their ICU stay. Patients must be ventilated within 48 h after ICU admission and not have any previous chronic neurologic or acute condition responsible for cognitive impairments that would hamper their participation in a phone interview. Three months after ICU discharge or death of the patient, a psychologist will contact the patient and family by phone. Post-traumatic stress syndrome will be evaluated using the Impact of Events Scale-Revised questionnaire, anxiety and depression symptoms using the Hospital Anxiety and Depression Scale questionnaire, both in patients and families, and memory recollection using the ICU Memory Tool Questionnaire in patients. The content of a randomized sample of diaries of each center will be analyzed using a grid. An interview of the patients in the intervention arm will be conducted 6 months after ICU discharge to analyze in depth how they use the diary.

DISCUSSION

This study will provide new insights on the impact of ICU diaries on post-traumatic stress disorders in patients and families after an ICU stay.

TRIAL REGISTRATION

ClinicalTrial.gov, ID: NCT02519725 . Registered on 13 July 2015.

Images of suffering depicted in diaries of family caregivers in the acute stage of necrotising soft tissue infection: A content analysis

OBJECTIVES

Severe necrotising soft tissue infections (NSTI) are rare life threatening rapidly progressing bacterial infections requiring immediate diagnosis and treatment. The aim of the study was to explore the experience of family caregivers of patients with necrotising soft tissue infection during the acute stage of disease.

METHODS

Our study had a qualitative descriptive binational design using qualitative content analysis to explore diaries written by close family members (n=15). Participants were recruited from university hospitals in Denmark and Sweden.

FINDINGS

Three main categories emerged: Trajectory, Treatment, and Patient & Family. The first helped us construct an overview of the NSTI trajectory showing issues of importance to patient and family caregivers. The following categories were analysed further to describe four themes central to the family caregiver experience: craving information, needing to be near, suffering separation and network taking over.

CONCLUSIONS

Necrotising soft tissue infections are uncommon causing shock and concern. Centralised treatment might involve physical separation of patient and family during the acute stage of illness. Family accommodations near the patient and accessibility to adequate communication devices at the bedside are recommended. Health professionals need to keep in mind the importance of information and reassurance on the wellbeing of the family and ultimately of the patient.

How to Increase the Quality of a Suffering Experience: Lessons Derived From the Diary Narratives of a Dying Adolescent Girl

Personal narratives are assumed to be primary sources of the essential meaning of lived experiences of dying. In this study, I analyzed the personal diary of Miraç Fidan, a terminally ill adolescent with advanced cancer who kept a diary until her death at the age of 15. Miraç’s Diary, also published as a book, was subjected to hermeneutic phenomenological narrative analysis. Inferences were drawn regarding the following basic elements: (a) The dynamics in which Miraç lived and (2) her perceptions of herself, her immediate environment, and her experiences. Suffering seems to be the main experience dominating Miraç’s life, which I examined with regard to two dimensions: suffering caused by inevitable factors and suffering caused by preventable/changeable factors. The results suggest that if various causes among contextual factors are neutralized, then the quality of the existential experience determined by the inevitable factors would increase.

The ICU patient diary-A nursing intervention that is complicated in its simplicity: A qualitative study

BACKGROUND

Writing a diary for intensive care patients has been shown to facilitate patientrecovery and prevent post-traumatic stress following hospitalisation.

AIM

This study aimed to describe the experiences of critical care nurses' (CCNs') in writing personal diaries for ICU patients.

METHOD

The study was conducted with a qualitative design. Ten CCNs from two hospitals participated. Data were collected with semi-structured interviews and analysed using a qualitative thematic content analysis.

FINDINGS

The result consists of a theme: Patient diary: a complex nursing intervention in all its simplicity, as well as four categories: Writing informatively and with awareness shows respect and consideration; The diary is important for both patient and CCN; To jointly create an organisation that facilitates and develops the writing; Relatives' involvement in the diary is a matter of course.

CONCLUSION

CCNs are aware of the diary's importance for the patient and relatives, but experience difficulties in deciding which patients should get this intervention and how to prioritize it. Writing a personal diary for an ICU patient is a nursing intervention that is complicated in its simplicity.

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

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN

A descriptive multicenter longitudinal qualitative design.

METHODS

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

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

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

OBJECTIVE

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

REVIEW METHOD USED/DATA SOURCES

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

RESULTS

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

CONCLUSIONS

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

The effects of cognitive intervention on cognitive impairments after intensive care unit admission

Patients who survive critical illness commonly suffer cognitive impairments. We aimed to study the effects of cognitive intervention to treat the long-term impairments observed among different populations of intensive care unit (ICU) survivors. The results showed that the intervention significantly suppressed the deterioration of cognitive function in these patients. Medical and neurological ICU survivors were more susceptible than post-anaesthesia ICU patients to severe cognitive damage. In the former, the deterioration of impairments can be slowed by cognitive intervention. In comparison, intervention exerted significantly positive effects on the recovery of the cognitive functions of post-anaesthesia care unit patients. Furthermore, young populations were more likely than older populations to recover from acute cognitive impairments, and the impairment observed among the older population seemed to be multi-factorial and irreversible.

[Nurses' perception, experience and knowledge of palliative care in intensive care units]

BACKGROUND

Adequate provision of palliative care by nursing in intensive care units is essential to facilitate a "good death" to critically ill patients.

OBJECTIVE

To determine the perceptions, experiences and knowledge of intensive care nurses in caring for terminal patients.

METHODOLOGY

A literature review was conducted on the bases of Pubmed, Cinahl and PsicINFO data using as search terms: cuidados paliativos, UCI, percepciones, experiencias, conocimientos y enfermería and their alternatives in English (palliative care, ICU, perceptions, experiences, knowledge and nursing), and combined with AND and OR Boolean. Also, 3 journals in intensive care were reviewed.

RESULTS

Twenty seven articles for review were selected, most of them qualitative studies (n=16). After analysis of the literature it has been identified that even though nurses perceive the need to respect the dignity of the patient, to provide care aimed to comfort and to encourage the inclusion of the family in patient care, there is a lack of knowledge of the end of life care in intensive care units' nurses.

CONCLUSION

This review reveals that to achieve quality care at the end of life, is necessary to encourage the training of nurses in palliative care and foster their emotional support, to conduct an effective multidisciplinary work and the inclusion of nurses in decision making.

Intensive care diaries to promote recovery for patients and families after critical illness: A Cochrane Systematic Review

OBJECTIVES

To assess the effect of an intensive care unit (ICU) diary versus no ICU diary on patients, and their caregivers or families, during the patient's recovery from admission to an ICU.

DESIGN

Systematic review of randomized controlled trials (RCTs) and clinical controlled trials.

DATA SOURCES

CENTRAL, MEDLINE, CINAHL, EMBASE, PsycINFO, PILOT; Web of Science Conference Proceedings, clinical trial registries and reference lists of identified trials.

REVIEW METHODS

Studies evaluated the effectiveness of patient diaries, when compared to no ICU diary, for patients or family members to promote recovery after admission to ICU were included. Outcome measures for describing recovery from ICU included the risk of post-traumatic stress disorder (PTSD), anxiety, depression and post-traumatic stress symptomatology, health-related quality of life and costs. We used standard methodological approaches as expected by The Cochrane Collaboration. Two review authors independently reviewed titles for inclusion, extracted data and undertook risk of bias according to pre-specified criteria.

RESULTS

We identified three eligible studies; two describing ICU patients (N=358), and one describing relatives of ICU patients (N=30). No study adequately reported on risk of PTSD as described using a clinical interview, family or caregiver anxiety or depression, health-related quality of life or costs. Within a single study there was no clear evidence of a difference in risk for developing anxiety (RR 0.29, 95% CI 0.07-1.19) or depression (RR 0.38, 95% CI 0.12-1.19) in participants who received ICU diaries, in comparison to those that did not receive a patient diary. Within a single study there was no evidence of difference in median post-traumatic stress symptomatology scores (diaries 24, SD 11.6; no diary 24, SD 11.6) and delusional ICU memory recall (RR 1.04, 95% CI 0.84-1.28) between the patients recovering from ICU admission who received patient diaries, and those who did not. One study reported reduced post-traumatic stress symptomatology in family members of patients recovering from admission to ICU who received patient diaries (median 19; range 14-28), in comparison to no diary (median 28; range 14-38).

CONCLUSIONS

Currently there is minimal evidence from RCTs of the benefits or harms of patient diaries for patients and their caregivers or family members. A small study has described their potential to reduce post-traumatic stress symptomatology in family members. However, there is currently inadequate evidence to support their effectiveness in improving psychological recovery after critical illness for patients and their family members.

The experiences of ICU patients during follow-up sessions--a qualitative study

OBJECTIVE

Evidence supports the recommendation for follow-up session(s) for patients after discharge from an intensive care unit (ICU). The aim of these follow-up sessions is to allow patients to express and discuss their experiences and problems following their time in an ICU. To optimise the knowledge gained from the follow-up session experience, it is necessary to describe how patients experience these sessions. The aim of this study was to describe how ICU-patients, experience a follow-up session.

DESIGN/SETTING

This study adopted a qualitative design utilising semi-structured interviews, and which examined the experiences of seven men and five women. Qualitative content analysis was utilised.

FINDINGS

The participants stated that the information gained from these sessions, which had previously seemed unclear to some of them, was, on the whole, now clarified and confirmed. A discernible difference was found between participants who were cared for on a general ward and those who were cared for on a rehabilitation ward and also were offered a meeting with a counsellor, following discharge their from the ICU. The findings also indicated that participants who were not offered psychosocial support showed a greater need for a follow-up session.

CONCLUSION

This study has highlighted the need for increasing collaboration between intensive care staff and staff in other units to provide support to this patient group in order to reduce their suffering post intensive care experience.

Diaries for recovery from critical illness

BACKGROUND

During intensive care unit (ICU) admission, patients experience extreme physical and psychological stressors, including the abnormal ICU environment. These experiences impact on a patient's recovery from critical illness and may result in both physical and psychological disorders. One strategy that has been developed and implemented by clinical staff to treat the psychological distress prevalent in ICU survivors is the use of patient diaries. These provide a background to the cause of the patient's ICU admission and an ongoing narrative outlining day-to-day activities.

OBJECTIVES

To assess the effect of a diary versus no diary on patients, and their caregivers or families, during the patient's recovery from admission to an ICU.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 1), Ovid MEDLINE (1950 to January 2014), EBSCOhost CINAHL (1982 to January 2014), Ovid EMBASE (1980 to January 2014), PsycINFO (1950 to January 2014), Published International Literature on Traumatic Stress (PILOTS) database (1971 to January 2014); Web of Science Conference Proceedings Citation Index - Science and Social Science and Humanities (1990 to January 2014); seven clinical trial registries and reference lists of identified trials. We applied no language restriction.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) or clinical controlled trials (CCTs) that evaluated the effectiveness of patient diaries, when compared to no ICU diary, for patients or family members to promote recovery after admission to ICU. Outcome measures for describing recovery from ICU included the risk of post-traumatic stress disorder (PTSD), anxiety, depression and post-traumatic stress symptomatology, health-related quality of life and costs.

DATA COLLECTION AND ANALYSIS

We used standard methodological approaches as expected by The Cochrane Collaboration. Two review authors independently reviewed titles for inclusion, extracted data and undertook risk of bias according to prespecified criteria.

MAIN RESULTS

We identified three eligible studies; two describing ICU patients (N = 358), and one describing relatives of ICU patients (N = 30). The study involving relatives of ICU patients was a substudy of family members from one of the ICU patient studies. There was a mixed risk of bias within the included studies. Blinding of participants to allocation was not possible and blinding of the outcome assessment was not adequately achieved or reported. Overall the quality of the evidence was low to very low. The patient diary intervention was not identical between studies. However, each provided a prospectively prepared, day-to-day description of the participants' ICU admission.No study adequately reported on risk of PTSD as described using a clinical interview, family or caregiver anxiety or depression, health-related quality of life or costs. Within a single study there was no clear evidence of a difference in risk for developing anxiety (risk ratio (RR) 0.29, 95% confidence interval (CI) 0.07 to 1.19) or depression (RR 0.38, 95% CI 0.12 to 1.19) in participants who received ICU diaries, in comparison to those that did not receive a patient diary. However, the results were imprecise and consistent with benefit in either group, or no difference. Within a single study there was no evidence of difference in median post-traumatic stress symptomatology scores (diaries 24, SD 11.6; no diary 24, SD 11.6) and delusional ICU memory recall (RR 1.04, 95% CI 0.84 to 1.28) between the patients recovering from ICU admission who received patient diaries, and those who did not. One study reported reduced post-traumatic stress symptomatology in family members of patients recovering from admission to ICU who received patient diaries (median 19; range 14 to 28), in comparison to no diary (median 28; range 14 to 38).

AUTHORS' CONCLUSIONS

Currently there is minimal evidence from RCTs of the benefits or harms of patient diaries for patients and their caregivers or family members. A small study has described their potential to reduce post-traumatic stress symptomatology in family members. However, there is currently inadequate evidence to support their effectiveness in improving psychological recovery after critical illness for patients and their family members.

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.

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.

Recovery post ICU

Many ICU patients struggle to recovery following critical illness and may be left with physical, cognitive and psychological problems, which have a negative impact on their quality of life. Gross muscle mass loss and weakness can take some months to recover after the patients' Intensive Care Unit (ICU) discharge, in addition critical illness polyneuropathies can further complicate physical recovery. Psychological problems such as anxiety, depression and post traumatic stress disorder (PTSD) are common and have an negative impact on the patients' ability to engage in rehabilitation after ICU discharge. Finally cognitive deficit affecting memory can be a significant problem. The first step in helping patients to recover from such a devastating illness is to recognise those who have the greatest need and target interventions. Research now suggests that there are interventions that can accelerate physical recovery and reduce the incidence of psychological problems such as anxiety, depression and PTSD. Cognitive rehabilitation, however, is still in its infancy. This review will look at the research into patients' recovery and what can be done to improve this where needed.

How much time do nurses need to write an ICU diary?

BACKGROUND

Diaries in the Intensive Care Unit (ICU) support patients and relatives during and after a stay on the ICU. Barriers to implementation of the ICU diary are workload, unwanted closeness to patients and lack of time.

AIMS AND OBJECTIVES

The purpose of the study was to evaluate the time nurses consume writing an ICU diary. Further questions were to examine whether the first diary entry, which includes a more detailed description about the admission, consumes more time than other entries and whether the time taken depends on experience or workload of the nurses.

DESIGN

Quantitative, prospective, international observational multicentre study in four ICUs within the international diary network in Germany (two ICUs), Sweden and Switzerland (one ICU each).

METHOD

During a 6-month period in 2012/2013 nurses measured the time they consumed writing a diary in minutes and seconds, the number of diaries they contributed to and total number of diary entries, the nurse-patient ratio, their level of experience in writing diaries, interruptions while writing in a diary and additional information like photographs or follow-up visits.

RESULTS

In summary 29 diaries were collected which included 195 written entries. The first entry needed significantly more time than following entries (first entry: mean 13:33 min versus following entries: mean 5:31, p < 0·001). The mean time for following entries differed significantly between the countries: Switzerland: 6:14, Sweden 5:31 and Germany 3:36 (p < 0·001). Nurses with more experience used more time to write a diary (not significant). With increasing nurse-patient-ratio the time decreased for following entries (ratio 1:1: mean 5:42, ratio 1:2: mean 5:27, ratio 1:3: mean 3:12, p = 0·007).

CONCLUSION

Writing a diary for patients and relatives means an additional amount of time and workload, but according to the increased quality of nursing the time seems to be feasible for implementation. The measured time was self-reported, thus including possible bias for the results.