The patient experience of intensive care: A meta-synthesis of Nordic studies

Being a patient in the intensive care unit: a narrative approach to understanding patients' experiences of being awake and on mechanical ventilation

PURPOSE

Intensive care patients often struggle to communicate due to the technical equipment used for mechanical ventilation and their critical illness. The aim of the study was to achieve a deeper understanding of how mechanically ventilated intensive care patients construct meaning in the unpredictable trajectory of critical illness.

METHODS

The study was a part of a larger study in which ten patients were video recorded while being in the intensive care. Five patients engaged in interviews about their experiences from the intensive care stay after being discharged and were offered the possibility to see themselves in the video recordings. A narrative, thematic analysis was applied to categorize the patients' experiences from the intensive care.

RESULTS

A pattern of shared experiences among intensive care patients were identified. Three main themes capture the patient's experiences: 1) perceiving the intensive care stay as a life-changing turning point, 2) being dependent on and cared for by others, and 3) living with negative and positive ICU experiences.

CONCLUSION

The patients' narratives revealed how being critically ill affected them, and how they understood their experiences in relation to themselves and their surroundings. The results can be used to pose important questions about our current clinical practice.

Opening Pandora's box by generating ICU diaries through artificial intelligence: A hypothetical study protocol

BACKGROUND

Patients and families on Intensive Care Units (ICU) benefit from ICU diaries, enhancing their coping and understanding of their experiences. Staff shortages and a limited amount of time severely restrict the application of ICU diaries. To counteract this limitation, generating diary entries from medical and nursing records using an artificial intelligence (AI) might be a solution.

DESIGN AND PURPOSE

Protocol for a hypothetical multi-center, mixed method study to identify the usability and impact of AI-generated ICU diaries, compared with hand-written diaries.

METHOD

A hand-written ICU diary will be written for patients with expected length of stay ≥ 72 h by trained nursing staff and families. Additionally at discharge, the medical and nursing records are analyzed by an AI software, transformed into understandable, empathic diary entries, and printed as diary. Based on an appointment with patients within 3 months, diaries are read in randomized order by trained clinicians with the patients and families. Patients and families will be interviewed about their experiences of reading both diaries. In addition, usability of diaries will be evaluated by a questionnaire.

EXPECTED FINDINGS AND RESULTS

Patients and families describe the similarities and differences of language and the content of the different diaries. In addition, concerns can be expressed about the generation and data processing by AI.

IMPLICATIONS FOR PRACTICE

Professional nursing involves empathic communication, patient-centered care, and evidence-based interventions. Diaries, beneficial for ICU patients and families, could potentially be generated by Artificial Intelligence, raising ethical and professional considerations about AI's role in complementing or substituting nurses in diary writing.

CONCLUSIONS

Generating AI-based entries for ICU diaries is feasible, but raises serious questions about nursing ethics, empathy, data protection, and values of professional nurses. Researchers and developers shall discuss these questions in detail, before starting such projects and opening Pandora's box, that can never be closed afterwards.

Patients' experiences with early rehabilitation in intensive care units: A qualitative study about aspects that influence their participation

AIM

To explore patients' experiences with early rehabilitation in the intensive care unit and what they perceive to influence their participation.

DESIGN

A qualitative design anchored in phenomenological and hermeneutical traditions utilizing in-depth interviews.

METHODS

Thirteen patients were interviewed from 5 to 29 weeks following discharge from three units, in January-December 2022. Analysed using systematic text condensation and the pattern theory of self. Reporting adhered to consolidated criteria for reporting qualitative research.

RESULTS

Interviews described four main categories: (1) A foreign body, how the participants experienced their dysfunctional and different looking bodies. (2) From crisis to reorientation, the transformation the participants experienced from a state of crisis to acceptance and the ability to look forwards, indicating how bodily dysfunctions are interlinked to breakdowns of the patients' selves and the reorganization process. (3) Diverse expectations regarding activity: ambiguous expectations communicated by the nurses. (4) Nurse-patient: a powerful interaction, highlighting the essential significance of positive expectations and tailored bodily and verbal interaction for rebuilding the patient's outwards orientation.

CONCLUSION

Outwards orientation and reorganization of the self through a reduction in bodily dysfunctions, strengthening the patients' acceptance of the situation, providing tailored expectations and hands-on and verbal interaction appear to be fundamental aspects of patient participation in early rehabilitation.

IMPLICATIONS

Insights into patients' perceptions show how dysfunctional bodies cloud individuals' perceptual fields, causing inwards orientation and negative thoughts concerning themselves, their capabilities, environment and future. This knowledge can improve nurses' ability to tailor care to promote optimal recovery for patients.

PATIENT OR PUBLIC CONTRIBUTION

User representative contributed to the design of the study.

Reimagine the ICU: Healthcare Professionals' Perspectives on How Environments (Can) Promote Patient Well-Being

OBJECTIVE

This study aims (1) to understand the needs and challenges of the current intensive care unit (ICU) environments in supporting patient well-being from the perspective of healthcare professionals (HCPs) and (2) to explore the new potential of ICU environments enabled by technology.

BACKGROUND

Evidence-based design has yielded how the design of environments can advocate for patient well-being, and digital technology offers new possibilities for indoor environments. However, the role of technology in facilitating ICU patient well-being has been unexplored.

METHOD

This study was conducted in two phases. First, a mixed-method study was conducted with ICU HCPs from four Dutch hospitals. The study investigated the current environmental support for care activities, as well as the factors that positively and negatively contribute to patient experience. Next, a co-creation session was held involving HCPs and health technology experts to explore opportunities for technology to support ICU patient well-being.

RESULTS

The mixed-method study revealed nine negative and eight positive patient experience factors. HCPs perceived patient emotional care as most challenging due to the ICU workload and a lack of environmental support in fulfilling patient emotional needs. The co-creation session yielded nine technology-enabled solutions to address identified challenges. Finally, drawing from insights from both studies, four strategies were introduced that guide toward creating technology to provide holistic and personalized care for patients.

CONCLUSION

Patient experience factors are intertwined, necessitating a multifactorial approach to support patient well-being. Viewing the ICU environment as a holistic unit, our findings provide guidance on creating healing environments using technology.

Understanding the needs and perceptions of early mobilization for critically ill patients: A systematic review of qualitative studies

OBJECTIVE

To synthesize qualitative research findings on intensive care patients' perceptions of early mobilization to identify their needs and understand the factors influencing their participation.

METHODS

Studies that explored patients' experiences of early mobilization within the intensive care unit were searched. A comprehensive search was conducted by searching five English and four Chinese electronic databases. The systematic review was carried out in line with the Joanna Briggs Institute methodology for systematic reviews of qualitative evidence, and also the thematic synthesis method was used to analyze the data.

RESULTS

A total of eight studies were included. Eight descriptive themes were formed: patients' self-determination needs, patients' relationship needs, patients' needs for competency and self-control, perceived benefits of physical function, increased self-confidence, negative emotions, unpleasant experiences and suffering, negative attitudes, and three analytical themes related to patients' perceptions of early mobilization in the intensive care unit were identified, including patients' needs during early mobilization, facilitators prompting patients' actions in early mobilization, and obstacles influencing patients' actions in early mobilization.

CONCLUSION

Many factors influence the critically ill patients' actions in early mobilization. A better understanding of patients' potential needs and psychological responses to early mobilization in the intensive care unit may help health professionals develop strategies to promote the quality of early mobilization.

IMPLICATIONS FOR CLINICAL PRACTICE

Recognizing and developing the strategies to meet the needs are essential to improve the patients' actions in early mobilization in the intensive care unit.. Therefore, understanding the relationship between needs support and patients' actions in early mobilization can help them provider better support services during mobilization.

Psychometric validation of the Kolcaba General Comfort Questionnaire in critically ill patients

BACKGROUND

There is a lack of validated tools to measure comfort in critically ill patients.

OBJECTIVE

The objective of this study was to evaluate the psychometric properties of the General Comfort Questionnaire (GCQ) in patients admitted to intensive care units (ICUs).

METHODOLOGY

A total of 580 patients were recruited, randomising the sample into two homogeneous subgroups of 290 patients for exploratory factor analysis and confirmatory factor analysis, respectively. The GCQ was used to assess patient comfort. Reliability, structural validity, and criterion validity were analysed.

RESULTS

The final version included 28 of the 48 items from the original version of the GCQ. This tool was named the Comfort Questionnaire (CQ)-ICU, maintaining all types and contexts of the Kolcaba theory. The resulting factorial structure included seven factors: psychological context, need for information, physical context, sociocultural context, emotional support, spirituality, and environmental context. A Kaiser-Meyer-Olkin value of 0.785 was obtained, with Bartlett's sphericity test (0.000) being significant, and the total variance explained was 49.750%. The Cronbach's alpha was 0.807, with subscale values ranging from 0.788 to 0.418. Regarding convergent validity, high positive correlations were obtained between the factors and the GCQ score, the CQ-ICU score, and the criterion item GCQ31: "I am content". In terms of divergent validity, correlations were low with the APACHE II scale and with the NRS-O except for physical context (-0.267).

CONCLUSION

The Spanish version of the CQ-ICU is a valid and reliable tool to assess comfort in an ICU population 24 h after admission. Although the resulting multidimensional structure does not replicate the Kolcaba Comfort Model, all types and contexts of the Kolcaba theory are included. Therefore, this tool enables an individualised and holistic evaluation of comfort needs.

Intensive care nurses' experiences of caring for isolated COVID-positive patients during first wave of COVID-19

Background

COVID-19 has fundamentally changed all fields of health care. Intensive care nurses have been at the forefront of the pandemic facing the massive impact of the disease, both professionally and personally. This study investigated nurses' experiences of caring for isolated COVID-19 positive patients in the intensive care department during the first wave of the COVID-19 pandemic. The study investigated how isolation affected the nurses themselves, how they related with their patients, and how isolation affected patient care in general.

Methods

The study was performed at a 20-bed university hospital intensive care department in Copenhagen, Denmark. COVID-19 positive patients were isolated or cohort isolated. A dedicated nurse cared for each isolated patient and wore full personal protective equipment. The study is based on in-depth phenomenological interviews with intensive care nurses conducted in summer 2020. The interviews were structured according to the principles of "Phenomenologically Grounded Qualitative Research." The data included observations from within the isolated patient rooms.

Findings

Six intensive care nurses participated in the study. The analysis documented following themes consistently reported by all nurses: (1) a general sense of uncanniness, (2) intense feelings of confinement and co-isolation, and (3) heightened senses of bodily objectification, including how nurses' experienced their patients and also themselves.

Conclusion

This is the first Scandinavian phenomenological study to focus on mapping the experiences of intensive care nurses during the extreme circumstances of the first wave of the COVID-19 pandemic. Further studies may explore long-term effects, such as psychiatric morbidity or psychological functioning in these individuals.

Experiences of isolation in patients in the intensive care unit during the COVID-19 pandemic

BACKGROUND

During the COVID-19 pandemic, patients in the intensive care unit have been subjected to strict isolation precautions, and potentially long and complicated patient courses. The aim of the study is to provide an investigation of the experiences of isolation in COVID-19-positive patients in the ICU during the first phase of the COVID-19 pandemic in Denmark.

METHODS

The study was performed in a 20-bed ICU at a university hospital in Copenhagen, Denmark. The study is based on a phenomenological framework, Phenomenologically Grounded Qualitative Research. This approach provides insights into the tacit, pre-reflective and embodied dimensions of the specific experience under investigation. Methods included a combination of in-depth structured interviews with ICU patients 6-12 months after ICU discharge, and observations from inside the isolated patient rooms. The descriptions of experiences gathered through the interviews were subjected to systematic thematic analysis.

RESULTS

Twenty-nine patients were admitted to the ICU in the period 10 March and 19 May 2020. A total of six patients was included in the study. Themes consistently reported across all patients included (1) being objectified to degrees that implied self-alienation; (2) feeling a sense of being in captivity; (3) being in an experiential state of surrealism, and finally (4) experiencing extreme loneliness and intercorporeal deprivation.

CONCLUSION

This study provided further insights into the liminal patient experiences of being isolated in the ICU due to COVID-19. Robust themes of experience were achieved through an in-depth phenomenological approach. Although, similarities in experiences compared to other patient groups exist, the precarious situation constituted by COVID-19 lead to significant intensifications across multiple parameters.

A scoping review of older patients' health-related quality of life, recovery and well-being after intensive care

AIMS

In the present study, we aimed to determine how Health-Related Quality of Life (HRQoL), recovery (function and capacity in daily life) and well-being are followed up and characterised in persons ≥65 years of age who were being cared for in an intensive care unit (ICU).

DESIGN

A scoping review.

METHODS

CINAHL, MEDLINE (Ovid) and PsycINFO databases were searched in October 2021. 20 studies met the inclusion criteria. The scoping review followed the principles outlined by Arksey and O'Malley, and the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) checklist and Joanna Briggs Institute (JBI) framework were used.

RESULTS

Results are presented under five subheadings: Study characteristics, Type of studies, Methods for follow-up, health-related quality of life, and Recovery. Time seems to be an important factor regarding HRQoL among older patients being cared for in an ICU, with most elderly survivors perceiving their HRQoL as acceptable after 1 year. Nevertheless, several studies showed patients' willingness to be readmitted to the ICU if necessary, indicating that life is worth fighting for.

PATIENT OR PUBLIC CONTRIBUTION

Due to the design of the study, this study involves no patient or public contribution.

Struggling to return to everyday life-The experiences of quality of life 1 year after delirium in the intensive care unit

BACKGROUND

Many critically ill patients report a change in their health-related quality of life after intensive care unit (ICU) discharge. Patients who experience delirium during their ICU stay are perceived as a fragile group of ICU survivors, and the 'quality of life' phenomenon needs to be studied among these patients.

AIM

To explore everyday life experiences of critically ill patients with delirium during the ICU stay, from ICU discharge until 1-year follow-up, focusing on their health-related quality of life and cognitive function.

STUDY DESIGN

We used a descriptive qualitative research design and interviewed patients 1 year after ICU admission. The participants were recruited from a pre-planned one-year follow-up study of 'Agents Intervening against Delirium for patients in the Intensive Care Unit trial'. Data were analysed using Framework Analysis Method and content analysis.

RESULTS

Nine women and eight men participated and reported a struggle when returning to everyday life or adapting to a new normality from hospital discharge to 1 year later. None of the participants had been aware of the challenges they would face after hospital discharge. They described a need for more information about these challenges to themselves and about primary care to better understand their situation and the struggles they experience during recovery. One overall theme emerged from the analysis 'From enduring to adapting' with three subthemes: 'Struggling to regain a functional life', 'Struggling to regain normal cognition' and 'Distressing manifestations from the ICU'.

CONCLUSIONS

To improve recovery and the quality of rehabilitation for critically ill patients suffering from delirium, it is essential to understand the phenomenon of ICU survivorship and what this fragile group of patients is going through. It is necessary to bridge the gap between secondary and primary care so patients can receive optimal training and support when needed.

RELEVANCE TO CLINICAL PRACTICE

Bridging the gap between primary and secondary healthcare services is urgently needed to improve rehabilitation for ICU survivors after critical illness.

The Experiences of Post-ICU COVID-19 Survivors: An Existential Perspective using Interpretative Phenomenological Analysis

COVID-19 has highlighted the vulnerability of intensive care unit (ICU) patients and the negative sequelae associated with ICU treatment. While the potentially traumatic impact of ICU is well documented, less is known about the ICU survivor's subjective experience and how it influences life post-discharge. Existential psychology addresses the universal concerns of existence, including death, isolation, and meaninglessness, and offers a holistic view of human experience beyond diagnostic categories. An existential psychological understanding of ICU COVID-19 survivorship may therefore provide a rich account of what it means to be among the worst affected by a global existential crisis. This study employed interpretive phenomenological analysis of qualitative interviews with 10 post-ICU COVID-19 survivors (aged 18-78). Interviews were structured on existential psychology's 'Four Worlds' model that explores the physical, social, personal, and spiritual dimensions of human experience. The essential meaning of ICU COVID-19 survival was conceptualised as 'Trying to Reconnect with a Changed Reality' and consisted of four themes. The first, Between Shifting Realities in ICU, described the liminal nature of ICU and the need to ground oneself. The second, What it Means to Care and Be Cared For, captured the emotive nature of personal interdependence and reciprocity. The third, The Self is Different, described survivors' struggle to reconcile old and new selves. The fourth, A New Relationship with Life, outlined how survivors' experiences shaped their new worldviews. Findings evidence the value of holistic, existentially informed psychological support for ICU survivors.

A Theoretically Informed Critical Review of Research Applying the Concept of Liminality to Understand Experiences with Cancer: Implications for a New Oncological Agenda in Health Psychology

Liminality was described more than 20 years ago as a major category explaining how cancer is experienced. Since then, it has been widely used in the field of oncology research, particularly by those using qualitative methods to study patient experience. This body of work has great potential to illuminate the subjective dimensions of life and death with cancer. However, the review also reveals a tendency for sporadic and opportunistic applications of the concept of liminality. Rather than being developed in a systematic way, liminality theory is being recurrently 're-discovered' in relatively isolated studies, mostly within the realm of qualitative studies of 'patient experience'. This limits the capacity of this approach to influence oncological theory and practice. In providing a theoretically informed critical review of liminality literature in the field of oncology, this paper proposes ways of systematizing liminality research in line with a processual ontology. In so doing, it argues for a closer engagement with the source theory and data, and with more recent liminality theory, and it sketches the broad epistemological consequences and applications.

Unidentified communication challenges in the intensive care unit: A qualitative study using multiple triangulations

BACKGROUND

Communication in the intensive care unit is challenged by patients' inability to speak owing to intubation, treatment, and illness. Research has focused on the use of communication tools or techniques, characteristics of the communication between patients and clinicians, and their experiences of communication challenges. However, few studies have combined the perspectives of patients, family members, and clinicians. We explored communication from different angles and investigated challenges that cannot be explained by ineffective use of aids and communication techniques.

OBJECTIVES

The aim of this study was to explore communication between patients, family members, and nurses and to investigate previously unidentified communication challenges.

METHODS

This study used a case-oriented design with multiple triangulations. It was conducted in two general intensive care units at a Norwegian university hospital. Participant observations were conducted on nine mechanically ventilated patients while communicating with family members and healthcare personnel. Following the observations, individual interviews were conducted with six patients, six family members, and nine healthcare personnel.

FINDINGS

Communication often seemed uncomplicated at the time of observations, but information from the interviews revealed another picture. We demonstrate what participants emphasised differently when they discussed their experiences, revealing a discrepancy in perceived importance in the situation. Family members had an important role in interpreting signs from the patient, uncovering challenges that would have been unknown to the nurses otherwise.

CONCLUSIONS

This study illustrates how communication challenges in the intensive care unit may not be perceptible to an observer or to all of the participants involved at the time of the communication. Nurses need to be aware of these communication challenges and realise that the patient might face issues that cannot be easily solved without extensive involvement of the patient, family, and nurses, and perhaps not even until a later stage in the patient's recovery process.

Communication with mechanically ventilated patients in intensive care units: A concept analysis

AIMS

The aim of this study was to perform a concept analysis of communication with mechanically ventilated patients in intensive care units and present a preliminary model for communication practice with these patients.

DESIGN

The Im & Meleis approach for concept analysis guided the study.

SEARCH METHODS

A literature search was performed in January 2022 in MEDLINE, Embase, CINAHL, psycINFO and Scopus, limited to 1998-2022. The main medical subject headings search terms used were artificial respiration, communication and critical care. The search resulted in 10,698 unique references.

REVIEW METHODS

After a blinded review by two authors, 108 references were included. Core concepts and terminology related to communication with mechanically ventilated patients were defined by content analytic methods. The concepts were then grouped into main categories after proposing relationships between them. As a final step, a preliminary model for communication with mechanically ventilated patients was developed.

RESULTS

We identified 39 different phrases to describe the mechanically ventilated patient. A total of 60 relevant concepts describing the communication with mechanically ventilated patients in intensive care were identified. The concepts were categorized into five main categories in a conceptual map. The preliminary model encompasses the unique communication practice when interacting with mechanically ventilated patients in intensive care units.

CONCLUSION

Highlighting different perspectives of the communication between mechanically ventilated patients and providers through concept analysis has contributed to a deeper understanding of the phenomena and the complexity of communication when the patients have limited possibilities to express themselves.

IMPACT

A clear definition of concepts is needed in the further development of guidelines and recommendations for patient care in intensive care, as well as in future research. The preliminary model will be tested further.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution, as this is a concept analysis of previous research.

Coercion in intensive care, an insufficiently explored issue-a scoping review of qualitative narratives of patient's experiences

Purpose

The use of coercion, in a clinical context as imposing a measure against a patient's opposition or declared will, can occur in various forms in intensive care units (ICU). One prime example of a formal coercive measure in the ICU is the use of restraints, which are applied for patients' own safety. Through a database search, we sought to evaluate patient experiences related to coercive measures.

Results

For this scoping review, clinical databases were searched for qualitative studies. A total of nine were identified that fulfilled the inclusion and the CASP criteria. Common themes emerging from the studies on patient experiences included communication issues, delirium, and emotional reactions. Statements from patients revealed feelings of compromised autonomy and dignity that came with a loss of control. Physical restraints were only one concrete manifestation of formal coercion as perceived by patients in the ICU setting.

Conclusion

There are few qualitative studies focusing on patient experiences of formal coercive measures in the ICU. In addition to the experience of restricted physical movement, the perception of loss of control, loss of dignity, and loss of autonomy suggests that restraining measures are just one element in a setting that may be perceived as informal coercion.

[The intensive care diary-a communication tool]

Diaries in intensive care units (ICU) are mostly written by families and nurses for patients with impaired consciousness. In the diary, the development of the patients is described in plain language by daily reports. Patients can read the diary later and process their experiences and, if necessary, reframe them differently. ICU diaries reduce the risks of psychosocial sequelae of patients and families and are now used worldwide. Diaries have different purposes and also serve as a communication tool: words are written to a person who will hopefully read them later. This can help families to stay connected and cope better with the situation. However, writing a diary can also be perceived as a burden by some relatives and nurses due to lack of time or because it seems to be too close. ICU diaries can serve as a tool for patientand family-centered care.

Becoming anonymous: how strict COVID-19 isolation protocols impacted ICU patients

In this article, I provide phenomenological reflections on patients' experiences of undergoing extreme isolation protocols while admitted to Intensive Care Units [ICU] during the first wave of COVID-19. Based on observation studies from within the patient isolation rooms and retrospective, in-depth phenomenological interviews with patients, I characterize this exceptional experience as one of becoming anonymous. To illustrate this, I start by establishing a perspective on embodied existence as constituted on a scale between anonymous embodiment and being enrooted into a personal niche. Against the backdrop of this framework, I illustrate how being admitted to the ICU under strict isolation protocols produced extraordinary experiences of becoming anonymous. Sources of the anonymization were: (1) Mechanical expropriation, pacification and disownership of the visceral-kinaesthetic body; (2) Objectification; (3) Spatial and intercorporeal anonymity (4) Surrealism: the intermingling of objective impressions and dream-like interpretations. Finally, I illustrate how anonymization induced an experience of embodiment as raw materiality, confronting the patient with what Martin Heidegger called the facticity of naked existence. This experience is discussed against Levinas' critique of Heidegger, while I propose that insights from this exceptional case may substantiate Heidegger's account.

What are the perceptions of intensive care staff about their sedation practices when caring for a mechanically ventilated patient?: A systematic mixed-methods review

Background

Sedation is used alongside mechanical ventilation for patients in intensive care units internationally; its use is complex and multifaceted. Existing evidence shows that the ways health care professionals use sedation significantly impacts patient outcomes, including how long someone spends on a ventilator, length of stay in intensive care and recovery.

Objective

Our study aimed to systematically review and synthesize qualitative and quantitative evidence about how intensive care staff perceive sedation practices when looking after sedated and mechanically ventilated patients.

Design

We performed a systematic integrated mixed-methods literature review collecting qualitative and quantitative studies according to inclusion and exclusion criteria. Studies were included if they were published from 2009 and focused on perceptions of staff working in general adult intensive care units and caring for mechanically ventilated patients.

Settings

General adult intensive care units.

Participants

Health care professionals working in adult intensive care units.

Methods

Screening, data extraction and quality appraisal was undertaken by SV. Screening for inclusion and quality issues were reviewed by TR, TM and JS. The following databases: Embase, BNI, PubMed, Scopus, AMED, CINAHL, ASSIA, The Cochrane Library and Google Scholar. We used an assessment tool called the Mixed Methods Appraisal Tool. The studies were assessed and analysed by transforming the qualitative and quantitative data into 'text-in-context' statements. The statements were then synthesized using thematic analysis.

Results

Eighteen studies were included from ten countries, fourteen quantitative and four qualitative. Three overarching themes were identified: 'Variation in Decision Making', 'Challenges in Decision Making' and 'Thinking Outside the Box'. Existing studies revealed that there is considerable variation in most aspects of perceived sedation practice. Staff face challenges with interprofessional collaboration and sedation practice, and there are barriers to using sedation protocols and light sedation. There is also evidence that there is a need for health care professionals to develop coping strategies to help them facilitate lighter sedation.

Conclusions

A review of a decade of evidence shows that variation in decision making and challenges in decision making should be addressed to improve the care of the sedated and ventilated patient, and improve the caregiving experience for staff. Staff continue to require support with sedation practice, especially in light sedation. Research should now focus on how to help staff cope with looking after lightly sedated patients. In addition, future studies should focus on exploring sedation practices using qualitative methods as there is a dearth of qualitative evidence.

Tweetable abstract

Staff perceive a range of complex challenges that explain some of the variability in sedation practice for the ventilated patient in ICU.

The Stressful Memory Assessment Checklist for the Intensive Care Unit (SMAC-ICU): Development and Testing

Stressful or traumatic memories of an intensive care stay may lead to long-term psychological morbidity. Memory assessment is therefore essential to aid in the patients’ recovery process. Acknowledging the large cohort of post ICU patients during the SARS-CoV-2 pandemic, a simple tool for the evaluation of ICU memories is needed. The aim of this study was, therefore, to develop and test the validity and reliability of a short stressful memory assessment checklist, including a distress intensity rating scale, for intensive care survivors. The consecutive sample consisted of 309 patients attending an intensive care follow-up consultation in Sweden. A methodological design was used consisting of four phases. The first three concerned construct and content validity and resulted in a 15-item checklist of potential stressful memories with a Likert-type scale including five response categories for distress intensity rating. To fill out the checklist, a median of 3 (2–3) minutes was needed. A test–retest approach yielded weighted kappa values between 0.419 and 0.821 for 12 of the single items and just below 0.4 for the remaining three. In conclusion, the stressful memory assessment checklist seems to be valid and reliable and can be used as a simple tool to evaluate the impact of stressful ICU memories.

The use of predefined scales and scores with eye-tracking devices for symptom identification in critically ill nonverbal patients

BACKGROUND

Eye tracking (ET) may be a novel tool to enable nonverbal communication. We hypothesized that ET could be used successfully by intensive care unit (ICU) patients with artificial airways to express their levels of pain and mood, quality of life, and self-esteem with predefined scales and scores.

METHODS

Prospective, monocentric, observational study, including patients with an endotracheal tube or tracheostomy tube and a history of mechanical ventilation for more than 48 hours without delirium, and inadequate nonverbal communication skills. The ICU patients' pain was assessed with a numeric rating scale, their mood was tested with a smiley analog scale. Quality of life and self-esteem were measured with the European quality of life-5 dimensions-5 levels-score and the visual analog self-esteem scale.

RESULTS

A total of 75 patients with a mean age of 58.3 years were included. Main diagnoses for ICU admission were major trauma (45.3%), nonabdominal sepsis (22.6%), and acute abdomen (13.3%). Patients showed moderate levels of pain and sadness with a median of 4 (interquartile range, 3-5.5) on the numeric rating scale and a median of 4 (interquartile range, 3-4) on the smiley analog scale. The general health status on the European quality of life-5 dimensions-5 levels-score was rated as poor. Reporting on the visual analog self-esteem scale, most of the included patients felt trapped (90.7%) and not confident (72%), were frustrated (64%) or did not feel understood (56%). However, despite their severe illness, many patients classified themselves as intelligent (30.6%), not mixed up (38.6%), outgoing (38.6%), and optimistic (44%).

CONCLUSION

Eye tracking enables symptom identification in critically ill voiceless patients with impaired communication options. The results of our study may provide guidance for improvement measures in the care of voiceless ICU patients. We believe that ET is useful for symptom identification and therefore may be capable of improving patient-medical team interaction and patient satisfaction.

LEVEL OF EVIDENCE

Diagnostic Test or Criteria, Level III.

Caught between ideals and reality: Phenomenological-hermeneutic study of healthcare providers' experiences while interacting with mechanically ventilated patients

This study aimed to explore healthcare providers' experiences of their communication and interaction with conscious patients on mechanical ventilation in intensive care. Nurses, physicians, and physiotherapists were interviewed after they had been video recorded in naturally occurring interactions with patients. The interviews were analyzed using a phenomenological-hermeneutical approach. Three themes were identified: The willingness to engage and understand the mechanically ventilated patient, the potential risk of neglecting the patient in the encounters, and provider interdependence as the core of intensive care. The themes elicited how providers handled the dissonance between their own personal ideals of care and their real-world encounters with patients and other professionals. The healthcare providers were aware of how easily patients could be neglected while being non-vocal, and therefore invested time and effort communicating with the patients. Based on their personal ideals of patient participation and autonomy, it was difficult to perform procedures, such as weaning off the ventilator or mobilization, to which the patient was opposed. Interprofessional collaboration was valued by the providers in such situations. The study revealed that providers need to consider the communication barriers that exist on the individual and team levels when interacting with patients on mechanical ventilation.

Understanding the Course of Critical Illness Through a Lifeworld Approach

An increasing number of individuals receive and survive intensive care treatment; however, several individuals experience problems afterward, which may threaten recovery. Grounded in a lifeworld approach, the aim of this study was to explore and describe what intensive care patients experience as limiting and strengthening throughout their illness trajectories. Ten former intensive care patients were interviewed three to eight months after hospital discharge. Using Giorgi's phenomenological analysis, a general structure of gaining strength through a caring interaction with others was revealed. The structure consisted of three constituents: feeling safe through a caring presence, being seen and met as a unique person, and being supported to restore capacity. Being met with a humanistic approach and individualized care appeared to be important, and the findings are discussed within the framework of lifeworld-led care. To facilitate improved aftercare of the critically ill, more tailored support throughout the illness trajectory is needed.

[The intensive care diary-a communication tool]

Tagebücher auf Intensivstationen werden meist von Familien und Pflegenden für Patient:innen mit Bewusstseinsstörungen geschrieben. In dem Tagebuch wird in laienverständlicher Sprache die Geschichte der Patient:innen anhand täglicher Berichte beschrieben. Patient:innen können später das Tagebuchbuch lesen und ihre Erfahrungen und Erlebnisse verarbeiten und ggf. anders bewerten. Intensivtagebücher senken die Risiken für psychosoziale Folgeschäden bei Patient:innen und Familien und sind mittlerweile weltweit verbreitet. Tagebücher haben unterschiedliche Zwecke und dienen auch der Kommunikation: Es werden Worte an eine Person geschrieben, die sie später hoffentlich lesen wird. Dies kann Familien darin unterstützen, verbunden zu bleiben und die Situation besser zu bewältigen. Gleichzeitig kann das Schreiben eines Tagebuchs auch von einigen Angehörigen und Pflegenden als Belastung empfunden werden, weil keine Zeit verfügbar ist oder es zu nahe scheint. Intensivtagebücher können als ein Mittel zur patienten- und familienzentrierten Versorgung genutzt werden.

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

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

"Humanizing intensive care: A scoping review (HumanIC)"

Significant scientific and technological advances in intensive care have been made. However, patients in the intensive care unit may experience discomfort, loss of control, and surreal experiences. This has generated relevant debates about how to humanize the intensive care units and whether humanization is necessary at all. This paper aimed to explore how humanizing intensive care is described in the literature. A scoping review was performed. Studies published between 01.01.1999 and 02.03.2020 were identified in the CINAHL, Embase, PubMed, and Scopus databases. After removing 185 duplicates, 363 papers were screened by title and abstract. Full-text screening of 116 papers led to the inclusion of 68 papers in the review based on the inclusion criteria; these papers mentioned humanizing or dehumanizing intensive care in the title or abstract. Humanizing care was defined as holistic care, as a general attitude of professionals toward patients and relatives and an organizational ideal encompassing all subjects of the healthcare system. Technology was considered an integral component of intensive care that must be balanced with caring for the patient as a whole and autonomous person. This holistic view of patients and relatives could ameliorate the negative effects of technology. There were geographical differences and the large number of studies from Spain and Brazil reflect the growing interest in humanizing intensive care in these particular countries. In conclusion, a more holistic approach with a greater emphasis on the individual patient, relatives, and social context is the foundation for humanizing intensive care, as reflected in the attitudes of nurses and other healthcare professionals. Demands for mastering technology may dominate nurses’ attention toward patients and relatives; therefore, humanized intensive care requires a holistic attitude from health professionals and organizations toward patients and relatives. Healthcare organizations, society, and regulatory frameworks demanding humanized intensive care may enforce humanized intensive care.

The patient and their family's perspectives on agitation and its management in adult critical care: A qualitative study

BACKGROUND

Agitation is frequently experienced by patients during critical illness, this is distressing for both the patient and their family. In addition, an acute episode of agitation can create management dilemmas for clinical teams. What is not understood is the patient and family's perspective of agitation and any subsequent management strategies employed.

OBJECTIVE

To understand the perspectives of patients and family members on the experience of agitation in adult critical care.

METHOD

An interpretive qualitative study using semi-structured interviews was undertaken with 13 participants, patient participants (n = 7) with the mean critical care length of stay 59 days (±70.88 days). Family members (n = 6) all opted to be interviewed with the patient present.

FINDINGS

Three themes generated from the data: 1) The recollection of sensations and delusions. 2) Communication and its impact. 3) Managing agitation, what helped and what did not.

CONCLUSION

The presence of family members has a positive effect on the patient during episodes of agitation. Their involvement in care requires promotion.

Patients' perception of medical communication and their needs during the stay in the intensive care unit

OBJECTIVE

To understand the perception of patients about medical communication as well as their needs during hospitalization in the intensive care unit.

METHODS

This study was cross-sectional descriptive and qualitative exploratory including 103 patients admitted to or recently discharged from the intensive care units of four hospitals in Greater Florianópolis, Santa Catarina state, Brazil. The patients' sociodemographic and clinical variables were studied, as were the score they gave to the quality of medical communication through the Quality of Communication Questionnaire and their spontaneous comments with reflections or justifications for the scores given, and their responses on how they felt and what complementary help they would have liked to receive. The quantitative data were analyzed by descriptive and analytical statistics, and the qualitative data were analyzed by thematic content analysis.

RESULTS

The mean Quality of Communication Questionnaire score was 5.1 (standard deviation - SD = 1.3), with 8.6 (SD = 1.3) on the general communication subscale and 2.1 (SD = 1.8) on the end-of-life communication subscale. The patients had a variable understanding of medical language. Some physicians seemed to be "rushed", according to some patients. Other patients would like to receive more frequent and detailed information and/or be respected and taken "more seriously" when they reported pain. Anxiety, sadness, and fear were among the reported feelings. Other needs included silence, more time for visits, the presence of a companion, psychological and social-work care, a bathroom that they could use, and better food in the intensive care unit.

CONCLUSION

The quality of medical communication with patients is good but could improve if physicians and the healthcare team had more time for patients. Other felt needs included respect, pain relief, and adjustments in the intensive care unit dynamics and environment.

Approach to the basic needs in patients on invasive ventilation using eye-tracking devices for non-verbal communication

PURPOSE

To analyze the feasibility of eye-tracking (ET) devices as a communicative approach to the basic needs (BN) of intensive care unit (ICU) and invasively ventilated nonverbal patients.

METHODS

Prospective, monocentric, and observational study including all patients without delirium, with an endotracheal tube or tracheostomy tube, with a history of invasive ventilation for more than 48 h, and inadequate nonverbal communication skills. The investigation was performed with commercially available ET devices (Tobii Dynavox I-15+) to express BN of ICU patients following a standardized 30-item yes-or-no questionnaire.

RESULTS

A total of 64 patients with a mean age of 58.6 years were included. The main diagnoses for ICU admission were major trauma (43.6%), sepsis (21.8%), and acute abdomen (15.6%). Pain during repositioning (69%), thirst (69%), sleep disorders (66%), fatigue (64%), and anxiety regarding the lifelong need for assistance (64%) were the main problems reported by the patients. However, most of the patients described expectations of health improvement (78%), good family support (66%), and an improvement in quality of life due to the use of ET devices (67%).

CONCLUSION

The use of ET in selected ICU patients with impaired communication is feasible, allowing them to express their BN. Apart from knowing the patients' individual BN, the results of our BN questionnaire may provide guidance for improvement measures in the care of patients in the ICU who are unable to speak. We believe that ET is useful for inquiring about and expressing BN and, therefore, may be capable of improving patient-medical team interactions and patient satisfaction.

The core qualities and competencies of the intensive and critical care nurse, a meta-ethnography

AIM

To develop a conceptual framework of the core qualities and competencies of the intensive and critical care nurse based on the experiences of intensive care patients, their relatives and the intensive and critical care nurses.

DESIGN

Meta-ethnography.

DATA SOURCES

A comprehensive, systematic search in seven databases supplemented with hand, citation and reference search. Sources published from 2007 to 2019 were included.

REVIEW METHODS

Noblit and Hare's understanding of meta-ethnography and the work of the eMERGE project have directed the synthesis.

RESULTS

Nineteen studies were included and synthesized into a conceptual framework. Overarching theme: 'feeling safe and being safe', subtheme: 'creating confidence and motivation' and conceptual categories (CCs): 'technical skills and biophysical knowledge'; 'inter/intra professional teamwork skills'; 'communication skills (with patients and their relatives)'; 'constant and attentive bedside presence'; 'creating participative care'; 'creating confidence through daily care'; 'creating a good atmosphere and having a supportive and encouraging attitude'; and 'building relationship to maintain self-esteem'.

CONCLUSION

By including the perspectives of intensive care patients, their relatives and intensive and critical care nurses, the core qualities and competencies comprise elements of both patient safety and the feeling of safety. The framework outlines concepts necessary to ensure person-centred and safe intensive care. Further research should involve each perspective to validate and strengthen the findings.

IMPACT

The development of standards and competence guidelines expressing the learning outcomes and qualification of intensive and critical care nurses should be based on input from intensive care patients, their relatives and intensive and critical care nurses. A variety of core qualities and competencies are necessary to create confidence and motivation, and to make the patient feel safe and be safe. This conceptual framework might form a basis for development of a program or assessment tool to facilitate excellence in education and practice in intensive care.

Experiences and Needs of Patients and Relatives During Hospitalization in an Intensive Care Unit in China: A Qualitative Study

INTRODUCTION

In comparison with Western cultures, the closed management system makes it difficult to implement family-centered nursing in many intensive care unit (ICU) in China. There are differences in cultural cognition and social environment between China and the West. The purpose of this study was to explore the experience and needs of critically ill patients and their relatives from a Chinese cultural perspective.

METHOD

This was a qualitative study using semistructured interviews conducted in a 26-bed integrated ICU at a Tertiary Grade A comprehensive hospital in Nantong, China. The participants included patients admitted in the ICU and their relatives. We used Colaizzi's seven-step procedure to analyze interview data.

FINDINGS

A total of 15 participants were recruited. Main categories within the patient perspective were variety of feelings, staff assistance required, and expectations for relatives. Patient opinions differed about the feelings of hospitalization and whether they needed the help of staff and relatives. The main categories from the relatives' perspective were life is disrupted, information needs, and emotional needs. Relatives of patients in the ICU experienced a lot of physical and mental pressure. The lack of timely understanding of the patient's condition and needs made them feel anxious.

CONCLUSION

The closed management system currently used in China limits contact between ICU patients and their relatives, increasing their physical and emotional discomfort. Hospitals in China should consider updating to a more open visiting policy based on current guidelines for family-centered care. Such policies enable staff to continue providing quality care for their patients while addressing patient and family needs.

Discharged from paediatric intensive care: A mixed methods study of teenager's anxiety levels and experiences after paediatric intensive care unit discharge

BACKGROUND

Teenagers represent a small proportion of patients on paediatric intensive care units (PICU) in the United Kingdom. During a time when their development is rapidly changing, an admission to PICU causes additional disruption. The impact of critical illness on psychological health after discharge has not been widely reported within this population.

AIM AND OBJECTIVES

To measure anxiety that teenagers report 48-96 hours and 4 weeks after discharge from PICU. To explore teenagers' experiences of being admitted onto PICU.

DESIGN

Two-phase mixed methods, explanatory sequential design.

METHODS

This single-site study was conducted between February and July 2018. An NHS Ethics committee approved the study. Teenagers were screened if they were aged 13-18 years old and had an elective or emergency admission to PICU for longer than 24 hours. Hospital Anxiety and Depression Scale, Anxiety subscale (HADS-A) was administered on paper and completed with the researcher present. Semi-structured interviews were conducted in-person and over the telephone, audio-recorded and transcribed verbatim. Data were analysed using inductive thematic analysis.

RESULTS

Nine of eighteen participants (50%) obtained scores indicating levels of anxiety which were mild (n = 3; 17%), moderate (n = 2; 11%), or severe (n = 4; 22%) 48-96 hours after PICU discharge. Four weeks later, all participants scored below the clinically significant cut-off level for the HADS-A-1 Teenagers described their experiences on PICU within three themes: Memories of treatments, side effects, and the PICU environment Losing a sense of self Feeling cared for CONCLUSIONS: Measured levels of anxiety had resolved in this small sample, 4 weeks after PICU discharge. This finding was not consistent with qualitative data that indicated that many experiences shared by participants were anxiety provoking.

RELEVANCE TO CLINICAL PRACTICE

Support for teenagers after PICU discharge should be available to meet individual needs; screening teenagers to identify support needs would be beneficial.

The core of patient-participation in the Intensive Care Unit: The patient's views

OBJECTIVES

Patient participation is an established concept in public welfare. However, reports of the phenomenon of patient participation during intensive care from the patient's point of view are scarce. Therefore, the aim of this study was to explore the meaning of patient participation in the intensive care unit from the patient's perspective.

RESEARCH DESIGN

A qualitative design was used for the purpose of the study with a purposive convenient sample of nine adult patients with memories from their intensive care stay.

METHOD

Data was collected through individual interviews and analysed using a phenomenological hermeneutical method.

FINDINGS

The results of our study show a variety of meanings and degrees of participation that continuously move on a sliding scale from acting as a captain to feelings of being on an isolated island. Patient participation varied due to individual cognitive abilities and individual preferences, and the caregiver's attention altered between the body and the person through the continuum of care.

CONCLUSION

Patient participation during ICU care is more than participation in decision-making processes or direct patient care decisions. An understanding of the concept participation from the individual patient is necessary to support person centred care and the patient's relatives play an important role in during the entire care process.

The central nervous system during lung injury and mechanical ventilation: a narrative review

Mechanical ventilation induces a number of systemic responses for which the brain plays an essential role. During the last decade, substantial evidence has emerged showing that the brain modifies pulmonary responses to physical and biological stimuli by various mechanisms, including the modulation of neuroinflammatory reflexes and the onset of abnormal breathing patterns. Afferent signals and circulating factors from injured peripheral tissues, including the lung, can induce neuronal reprogramming, potentially contributing to neurocognitive dysfunction and psychological alterations seen in critically ill patients. These impairments are ubiquitous in the presence of positive pressure ventilation. This narrative review summarises current evidence of lung-brain crosstalk in patients receiving mechanical ventilation and describes the clinical implications of this crosstalk. Further, it proposes directions for future research ranging from identifying mechanisms of multiorgan failure to mitigating long-term sequelae after critical illness.

A phenomenological study on the experiences of patient transfer from the intensive care unit to general wards

Objectives

This study aimed to derive an in-depth understanding of the transfer experience of intensive care unit (ICU) patients in South Korea through a phenomenological analysis.

Methods

Participants were 15 adult patients who were admitted to a medical or surgical ICU at a university hospital for more than 48 hours before being transferred to a general ward. Data were collected three to five days after their transfer to the general ward from January to December 2017 through individual in-depth interviews and were analyzed using Colaizzi’s phenomenological data analysis method, phenomenological reduction, intersubjective reduction, and hermeneutic circle. Data analysis yielded eight themes and four theme clusters related to the unique experiences of domestic ICU patients in the process of transfer to the general ward.

Results

The four main themes of the patients’ transfer experiences were “hope amid despair,” “gratitude for being alive,” “recovery from suffering,” and “seeking a return to normality.”

Conclusion

Our findings expand the realistic and holistic understanding from the patient’s perspective. This study’s findings can contribute to the development of appropriate nursing interventions that can support preparation and adaptation to the transfer of ICU patients.

Giving Voice: Nurse-Patient Communication in the Intensive Care Unit

Communication is the essence of the nurse-patient relationship. The critical care nurse's role in facilitating patient communication and enabling communication between patients and their families has never been more important or poignant than during the COVID-19 pandemic. We have witnessed tremendous examples of resourceful, caring nurses serving as the primary communication partner and support for isolated seriously ill patients during this pandemic. However, evidence-based tools and techniques for assisting awake, communication-impaired, seriously ill patients to communicate are not yet systematically applied across all settings. Missed communication or misinterpretation of patients' messages induces panic and fear in patients receiving mechanical ventilation and can have serious deleterious consequences. This lecture presents a 23-year program of research in developing and testing combination interventions (eg, training, tailored assessment, and tools) for best practice in facilitating patient communication during critical illness. Evidence from related nursing and inter pro fessional research is also included. Guidance for unit-based assessment, tailoring, and implementation of evidence-based patient communication protocols also is provided.

Patients' experiences of well-being when being cared for in the intensive care unit-An integrative review

OBJECTIVE

The aim of this integrative review was to identify facilitators and barriers to patients' well-being when being cared for in an ICU setting, from the perspective of the patients.

BACKGROUND

To become critically ill and hospitalised in an ICU is a stressful, chaotic event due to the life-threatening condition itself, as well as therapeutic treatments and the environment. A growing body of evidence has revealed that patients often suffer from physical, psychological and cognitive problems after an ICU stay. Several strategies, such as sedation and pain management, are used to reduce stress and increase well-being during ICU hospitalisation, but the ICU experience nevertheless affects the body and mind. DESIGN; METHODS: Since research exploring patients' sense of well-being in an ICU setting is limited, an integrative review approach was selected. Searches were performed in CINAHL, Medline, Psych Info, Eric and EMBASE. After reviewing 66 studies, 12 studies were included in the integrative review. Thematic analysis was used to analyse the studies. The PRISMA checklist for systematic reviews was used.

RESULTS

The results are presented under one main theme, 'Well-being as a multidimensional experience-interwoven in barriers and facilitators' and six sub-themes representing barriers to and facilitators of well-being in an ICU. Barriers identified were physical stressors, emotional stressors, environmental disturbances and insecurity relating to time and space. Facilitators were meeting physical needs and activities that included dimensions of a caring and relational environment.

CONCLUSION

Our main findings were that experiences of well-being were multidimensional and included physical, emotional, relational and environmental aspects, and they were more often described through barriers than facilitators of well-being.

RELEVANCE FOR CLINICAL PRACTICE

This integrative review has shown that it is necessary to adopt an individual focus on patient well-being in an ICU setting since physical, emotional, relational and environmental stressors might impact each patient differently.

Critically ill patients' experience of agitation: A qualitative meta-synthesis

BACKGROUND

Acute episodes of agitation are frequently experienced by patients during critical illness, yet what is not understood is the experience of agitation from the patient and family perspectives.

AIMS AND OBJECTIVES

To search existing literature, appraise it and then provide a synthesized interpretation to broaden the understanding of patients' and their families' experience of agitation during an adult critical care admission.

DESIGN

Qualitative meta-synthesis.

METHODS

A qualitative meta-synthesis based on a systematic literature search registered with PROSPERO. The search conducted between July and September 2019 was applied to ProQuest, Cumulative Index to Nursing and Allied Health, British Nursing Index, Cochrane Library, Ovid Medline, Web of Science, and PsycINFO databases. We appraised the selected literature and presented a synthesized interpretation. Analysis was based on the approach of Gadamerian hermeneutics. Due to the lack of data identified; the family experiences of agitation could not be addressed within the review.

RESULTS

In total, 8 studies were included capturing the experiences of 494 patients, aged between 18 and 92 years, with 225 (45%) women. The analysis generated three core themes: (a) What is real, what is not, (b) loss of communication and dependency, and (c) what helps, what does not. Fear of death, the emotion of anxiety, and feelings of pain alongside transient periods of fluctuating conscious levels provoked a feeling of intense vulnerability. The loss of effective communication and the feeling of dependence incite agitation and distress.

CONCLUSIONS

The patient's recollection of their critical illness can be completely or partially absent and disjointed with uncertainty around what is real and what is not. Family members observe the full effect of the patient's critical care illness and could be a wealth of untapped information.

RELEVANCE TO CLINICAL PRACTICE

Increasing awareness of the critically ill patients' experience of agitation highlights possible contributing factors to agitation development, such as staff interaction and communication skills, and the critical care environment.

Ethical dilemmas embedded in performing fieldwork with nurses in the ICU

Background:

Background: In general, qualitative research design often involves merging together various data collection strategies, and researcher’s may need to be prepared to spend longer periods in the field to pursue data collection opportunities that were not foreseen. Furthermore, nurse researchers performing qualitative research among patients and their relatives often experience unforeseen ethical dilemmas.

Aim:

This paper aimed to explore aspects of ethical dilemmas related to qualitative nursing research among patients and their relatives in the intensive care unit (ICU).

Research design:

This paper is based on a qualitative researcher’s personal experience during a hermeneutic phenomenological study involving close observation and in-depth interviews with 11 intensive care nurses. Data were collected at two ICUs in two Norwegian university hospitals.

Ethical considerations:

The study was approved by the Norwegian Social Science Data Services (NSD). The Regional Committee for Medical and Health Research Ethics (REK) granted dispensation to the project regarding health personnels confidentiality of the patients who were present during the observation (2012/622-4).

Findings:

Close observation with nurses in the ICU requires the researcher to balance being a qualitative researcher, an ICU nurse and a sensitive fellow human being open to the suffering of the other—that is, being embodied, engaged and affected by sensitive situations and simultaneously constantly stepping back and reflecting on the meaning of those situations.

Conclusions:

The qualitative researcher’s ethical awareness also entails knowing and acknowledging his or her own vulnerability, which becomes apparent in the researcher-participant relationship and settings in which being a fellow human always overrules the researcher’s role in ethical dilemmas.

Health Promotion Among Long-Term ICU Patients and Their Families

Few patients are as helpless and totally dependent on nursing as long-term intensive care (ICU) patients. How the ICU nurse relates to the patient is crucial, both concerning the patients’ mental and physical health and well-being. Even if nurses provide evidence-based care in the form of minimum sedation, early mobilization, and attempts at spontaneous breathing during weaning, the patient may not have the strength, courage, and willpower to comply. Interestingly, several elements of human connectedness have shown a positive influence on patient outcomes. Thus, a shift from technical nursing toward an increased focus on patient understanding and greater patient and family involvement in ICU treatment and care is suggested. Accordingly, a holistic view including the lived experiences of ICU care from the perspectives of patients, family members, and ICU nurses is required in ICU care as well as research.

Considerable research has been devoted to long-term ICU patients’ experiences from their ICU stays. However, less attention has been paid to salutogenic resources which are essential in supporting long-term ICU patients’ inner strength and existential will to keep on living. A theory of salutogenic ICU nursing is highly welcome. Therefore, this chapter draws on empirical data from three large qualitative studies in the development of a tentative theory of salutogenic ICU nursing care. From the perspective of former long-term ICU patients, their family members, and ICU nurses, this chapter provides insights into how salutogenic ICU nursing care can support and facilitate ICU patients’ existential will to keep on living, and thus promoting their health, survival, and well-being. In a salutogenic perspective on health, the ICU patient pathway along the ease/dis-ease continuum reveals three stages; (1) The breaking point, (2) In between, and (3) Never in my mind to give up. The tentative theory of salutogenic long-term ICU nursing care includes five main concepts: (1) the long-term ICU patient pathway (along the salutogenic health continuum), (2) the patient’s inner strength and willpower, (3) salutogenic ICU nursing care (4), family care, and (5) pull and push. The salutogenic concepts of inner strength, meaning, connectedness, hope, willpower, and coping are of vital importance and form the essence of salutogenic long-term ICU nursing care.

[Use of coercive measures in the intensive care unit]

Zwangsbehandlungen in der Medizin umfassen Maßnahmen, die gegen eine aktuelle oder frühere Willensäußerung der betroffenen Person durchgeführt werden. Hierunter fällt auch die Überwindung manifestierter Widerstände z. B. bei nicht einwilligungsfähigen Patienten. Zwang gibt es nicht nur in der Psychiatrie, sondern kann auch auf der Intensivstation ausgeübt werden. Im Spannungsfeld zwischen intensivmedizinischer Behandlung, Fürsorge und Patientenwille besteht ein hohes Risiko für Zwangsbehandlungen sowie freiheitseinschränkende Maßnahmen. Häufig ist dem Team dieses moralische Spannungsfeld nur zum Teil bewusst. Vom Patienten wird Zwang als Kontrollverlust beschrieben und kann als traumatisierend, entwürdigend und stressauslösend wahrgenommen werden. Die Herausforderung für das Team einer hochspezialisierten Intensivstation besteht darin, den Patienten in seiner Individualität zu sehen und so weit wie möglich einzubinden. Um Zwang auf Intensivstation zu vermeiden und dem individuellen Patienten gerecht zu werden, muss die Problematik zuallererst wahrgenommen werden. Hilfreich zur Vermeidung von Zwang auf einer Intensivstation können Ausbildungskonzepte, eine ethische Reflexion im Team (Teamkultur), Supervision und psychologische Begleitung für Patienten und das Team sowie klinikinternen Standards sein. Diese Arbeit beschreibt Ursachen, verschiedene Formen und Häufigkeiten von Zwangsbehandlungen auf der Intensivstation sowie juristische Vorgaben. Es wird eine Annäherung versucht, welche intensivmedizinischen Maßnahmen mit der Ausübung von Zwang einhergehen können und wie Zwang von Patienten und dem Team wahrgenommen wird.

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.

Space and place for health and care

Purpose: This discussion paper aims to contribute to a greater understanding of the state of the art of research engaged with conceptual matters of space and place for health and care. Method: The authors, who represent a variety of academic disciplines, discuss and demonstrate the conceptual recognition of space and place in research in health and caring sciences building upon own work and experience. Results: To explore the concepts of space and place for health and care is a research pursuit of utmost importance, and should be made through transdisciplinary research collaborations, whereby spatial theories from various disciplines could be communicated to cultivate truly novel and well-informed research. Furthermore, engaging with relational and topological perceptions of space and place poses methodological challenges to overcome in future research on health and care. Conclusions: We argue that there is a need for accelerating spatially informed research on health and care that is informed by current theories and perspectives on space and place, and transdisciplinary research collaborations are a means to achieving this.

Patient involvement in micro-decisions in intensive care

OBJECTIVE

The objective of this study was to explore how bedside micro-decisions were made between conscious patients on mechanical ventilation in intensive care and their healthcare providers.

METHODS

Using video recordings to collect data, we explored micro-decisions between 10 mechanically ventilated patients and 60 providers in interactions at the bedside. We first identified the types of micro-decisions before using an interpretative approach to analyze the decision-making processes and create prominent themes.

RESULTS

We identified six types of bedside micro-decisions; non-invited, substituted, guided, invited, shared and self-determined decisions. Three themes were identified in the decision-making processes: 1) being an observer versus a participant in treatment and care, 2) negotiating decisions about individualized care (such as tracheal suctioning or medication),and 3) balancing empowering activities with the need for energy restoration.

CONCLUSION

This study revealed that bedside decision-making processes in intensive care were characterized by a high degree of variability between and within patients. Communication barriers influenced patients' ability to express their preferences. An increased understanding of how micro-decisions occur with non-vocal patients is needed to strengthen patient participation.

PRACTICE IMPLICATIONS

We advise providers to make an effort to solicit patients' preferences when caring for critically ill patients.

Nurses' communication with mechanically ventilated patients in the intensive care unit: Umbrella review

AIM

To conduct a review summarizing evidence concerning communication with mechanically ventilated patients in the intensive care unit (ICU).

BACKGROUND

ICU patients undergoing mechanical ventilation are unable to communicate verbally, causing many negative emotions. Due to changes in sedation practice, a growing number of patients are conscious and experience communication difficulties.

DESIGN

The umbrella review method guided by the Joanna Briggs Institute was applied.

DATA SOURCES

A systematic search was done in the Cochrane Library, the Joanna Briggs Institute database, Cinahl, Pubmed, PsycINFO and Scopus between January -April 2019. Search terms were 'nurse-patient communication', 'mechanical ventilation', 'intensive care', and 'reviews as publication type'. Literature from 2009-2019 was included.

REVIEW METHODS

Following recommendations by the Joanna Briggs Institute, a quality appraisal, data extraction, and synthesis were done.

RESULTS

Seven research syntheses were included. There were two main themes and six subthemes: (1) Characterization of the nurse-patient communication: (a) Patients' communication; (b) Nurses' communication; (2) Nursing interventions that facilitate communication: (a) Communication assessment and documentation; (b) Communication methods and approaches; (c) Education and training of nurses; and (d) Augmentative and alternative communication.

CONCLUSION

Nurse-patient communication was characterized by an unequal power relationship with a common experience - frustration. Four key interventions were identified and an integration of these may be key to designing and implementing future ICU communication packages.

IMPACT

Nurse-patient communication is characterized by an unequal power relationship with one joint experience - frustration. Four key interventions should be integrated when designing and implementing communication packages in the ICU. Findings are transferable to ICU practices where patients are conscious and experience communication difficulties.

From fear to fight: Patients experiences of early mobilization in intensive care. A qualitative interview study

INTRODUCTION

Early mobilization (EM) in intensive care is frequently used to prevent physical and psychological complications, with promising results. However, the patient´s perception of EM has been sparsely investigated. Purpose: To investigate the experience of EM in patients treated in intensive care. Method: Nineteen former patients who had been treated in intensive care were interviewed. The interviews were analyzed using qualitative, inductive content analysis. Results: The analysis resulted in three categories; 1) Facing the impossible - a too demanding situation; 2) Struggling successfully on the way back; and 3) Need of having dedicated supporters. Conclusion: A considerable variety of experiences of EM were described in this study, both negative and positive. Prominent features were that pleasant emotions and great physical effort occurred simultaneously and that interaction and cooperation with the caregivers was paramount. To regain independence was another prominent feature, with EM considered to be of great importance in the recovery process. Moving to an upright position and ambulating appears to be beneficial to both body and mind. EM should therefore be among the first priorities in intensive care. EM should be practiced with respect and support, while encouraging and challenging the patient to strive for independence.

[Stressors for patients in the intensive care unit : An analysis taking controllability into consideration]

OBJECTIVE

Studies on stress factors for patients in intensive care units (ICU) have so far concentrated on whether certain stressors have occurred or how stressful they were. There are no studies on stress for patients in ICUs that measured both the perception of stress and the chances perceived to control it; however, loss of control can result in long-term psychopathological consequences, such as depression or posttraumatic stress disorder. Therefore, a questionnaire was developed to evaluate the influence of controllability on perception of stress. The aim of this study was to answer the following questions: which situations were experienced as stressful by patients in ICUs, whether patients perceived them as being controllable and whether the experience of stress depended on the controllability? Furthermore, it was examined which stressful situations are specific to ICUs.

MATERIAL AND METHODS

The questionnaire included 18 potentially stressful situations for ICU patients. These situations were assessed with respect to the occurrence, frequency and duration, the impact of stress and the perception of control. In addition, anxiety was assessed using STAI-X1. A total of 198 ICU patients and 100 patients hospitalized in a general surgery ward were interviewed.

RESULTS

Patients in ICUs remembered significantly more stressful situations than those on the normal ward (M ± SD = 10.2 ± 2.7 vs. 6.6 ± 2.0; d = 1.48; p < 0.001) and perceived them as more stressful (mean stress: M ± SD = 3.6 ± 1.5 vs. 2.2 ± 1.3; d = 1.01; p < 0.001). The most stressful situations for ICU patients were fixation of the arms (M ± SD = 7.47 ± 3.27), mechanical ventilation (M ± SD = 7.36 ± 3.29) and endotracheal suctioning (M ± SD = 7.19 ± 2.99). Approximately one third of patients underwent these situations. Situations experienced by more than 90% of ICU patients were evaluated as being the least stressful experiences, including infusion (M ± SD = 2.7 ± 2.7), measuring heart activity (M ± SD = 2.3 ± 2.7), taking blood samples (M ± SD = 2.2 ± 2.7), and temperature control (M ± SD = 0.9 ± 1.7). Controllability experienced by ICU patients negatively correlated with anxiety (r = -0.20, p = 0.004) and mean sensation of stress (r = -0.36; p < 0.001). When comparing stress levels of ICU patients who perceived controllability in a given situation to those who did not, the greatest effects (Cohen's d > 1.4) were observed for the situations presence of a bed barrier (M ± SD = 0.1 ± 0.4 vs. 5.9 ± 2.8), lighting at night (M ± SD = 0.7 ± 1.7 vs. 5.7 ± 3.3), presence of a ventilation tube (M ± SD = 2.5 ± 2.1 vs. 6.7 ± 3.0) and repositioning of the patient (M ± SD = 2.5 ± 2.9 vs. 6.7 ± 2.9).

CONCLUSION

The experience of loss of control seems to negatively modify the impact of stressors. Thus, an increase in aspects of controllability could reduce the burden on patients during intensive care.

"Please mind the gap": A secondary analysis of discomfort and comfort in intensive care

AIMS AND OBJECTIVES

To explore in depth discomfort in intensive care as experienced by patients and attended to by critical care nurses.

BACKGROUND

Discomfort in illness is complex and persistent, and its alleviation is a challenge for nurses working in intensive care units (ICU). In previous studies, we showed that ICU patients described little actual pain but suffer from much discomfort. Critical care nurses had a systematic approach to the treatment of pain, but were more haphazard in dealing with other types of discomfort.

DESIGN

Secondary qualitative analysis of data from two previous exploratory studies.

METHODS

Content analysis was used on existing data from 28 interviews with ICU patients, and 16 field notes and interviews with critical care nurses. Kolcaba's Comfort Theory was applied for further analysis. The COREQ checklist was used.

RESULTS

Three themes, "Being deprived of a functioning body", "Being deprived of a functioning mind" and "Being deprived of integrity" characterised the discomfort experienced by ICU patients. The nurses appeared to attend to all areas of discomfort expressed by patients. In need of, and providing acknowledgment and alleviation became a common overarching theme. We identified a comfort gap caused by the discrepancy between the patients' needs and the nurses' achievements in fulfilling these needs.

CONCLUSIONS

A gap exists between ICU patients' comfort needs and nurses' achievements in fulfilling these, indicating that discomfort currently is an inevitable part of the critical illness trajectory. Increased knowledge about how the brain is affected in ICU patients and more systematic approaches to assessing comfort needs and enhancing comfort may support nurses in fulfilling patient needs and possibly diminish the existing comfort gap.

RELEVANCE FOR CLINICAL PRACTICE

An increased understanding of the complex experience of discomfort in ICU patients may bring about more systematic approaches to enhance comfort and direct for education and further research.

To stay in touch - intensive care patients' interactions with nurses during mobilisation

BACKGROUND

Minimal sedation has made it possible to communicate and cooperate with intensive care patients and mobilisation can start earlier during their stay in the intensive care unit.

PURPOSE

To investigate the intensive care patient's reaction and interaction to mobilisation.

METHOD

This study used focused ethnography combining observations, interviews and four scores for evaluating awareness, and pain levels were included: Richmond Agitation Sedation Scale Confusion Assessment Method For The Intensive Care Unit, Numeric Rating Scale and Critical Pain Observation Tool. Twelve patients were observed during mobilisation, with subsequent interviews of the involved nurses.

FINDINGS

Nurses run the risk of overlooking the patient's reactions, such as pain, discomfort or needs during mobilisation. Nurses use several different ways of communicating to create contact with the patients. Patients with an impaired awareness level become more aware during mobilisation.

CONCLUSIONS

If the nurse's attention is focused on the technical side of caregiving, there is a risk that she might overlook the patient's reactions and needs. If the nurse is aware of the risk of overlooking the patient's reactions, she may plan the mobilisation to ensure that the patient gets the necessary attention and is included in the process. In that way, the patient might avoid unnecessary discomfort and maintain trust and confidence in the nurse.

The Patient's Situation During Interhospital Intensive Care Unit-to-Unit Transfers: A Hermeneutical Observational Study

Interhospital intensive care unit-to-unit transfers are an increasing phenomenon, earlier mainly studied from a patient safety perspective. Using data from video recordings and participant observations, the aim was to explore and interpret the observed nature of the patient's situation during interhospital intensive care unit-to-unit transfers. Data collection from eight transfers resulted in over 7 hours of video material and field notes. Using a hermeneutical approach, three themes emerged: being visible and invisible; being in a constantly changing space; and being a fettered body in constant motion. The patient's situation can be viewed as an involuntary journey, one where the patient exists in a constantly changing space drifting in and out of the health personnel's attention and where movements from the journey become part of the patient's body. Interhospital transfers of vulnerable patients emerge as a complex task, challenging the health personnel's ability to maintain a caring atmosphere around these patients.