Hong Kong patients' experiences of intensive care after surgery: nurses' and patients' views

Pain perception of patients in intensive care unit after cardiac surgery: A qualitative study using Roy's Adaptation Model

BACKGROUND

Although research on postoperative pain has increased, postoperative pain management is still a problem today. Most patients experience moderate to severe pain after cardiac surgery. As a result of pain, patients show inefficient adaptation behaviour in physiologic, role function, self-concept, and interdependence modes.

AIM

This study was conducted to examine the pain perceptions of intensive care patients after cardiac surgery according to Roy's Adaptation Model (RAM).

STUDY DESIGN

A qualitative design with a phenomenological approach was used in the study. The research data were collected by using a "descriptive information form", a "semi-structured interview form", and the "numerical rating scale" through the "in-depth interview method". The study sample consisted of 16 patients who were aged 18 years or older, had undergone cardiac surgery, experienced pain post-operatively in the intensive care unit at least once, and had intensive care experience. Patients with neuropathic or chronic pain or neurological or psychiatric disorders were not included in the study. Data were classified into physiologic, self-concept, and interdependence modes according to RAM.

RESULTS

The themes and sub-themes that emerged included physiologic modes (pain responses), self-concept modes (pain self-management), role-function modes (effects of pain), and interdependence modes (support systems in pain).

CONCLUSIONS

The results of our study can enable patients and nurses to communicate effectively about pain. In future studies, the effect of model-based pain management programs on cardiac surgery patients can be investigated.

RELEVANCE TO CLINICAL PRACTICE

Examining the pain perceptions of intensive care patients after cardiac surgery according to RAM will guide the improvement and development of pain management. It is thought that the model addresses intensive care patients experiencing pain holistically.

Hong Kong general ward nurses' experiences of transitional care for patients discharged from the intensive care unit: An inductive thematic analysis

OBJECTIVES

The aim of this study was to explore and better understand the experiences of Hong Kong general ward nurses who care for post-intensive care patients.

RESEARCH METHODOLOGY/DESIGN

Inductive thematic analysis and focus groups interviews were used in this study.

SETTING

A purposive sample of 20 ward-based registered nurses were recruited, formed five focus groups and interviewed online using video-conferencing media.

FINDINGS

The ward nurses in this study described the difficulties and challenges they experienced caring for the post-intensive care patient. Issues around workload and patient allocation figured highly along with a lack of education and training. Many felt scared and helpless when caring for these patients which significantly increased their anxiety. Some were compelled to spend more time with their other patients while others were so consumed with the post-ICU patient that they often neglected their other patients. The handover from the intensive care unit nurse was filled with trepidation and concern because of the level of information being handed-over was alien and complex to them so was the medications and the level of monitoring the intensive care unit nurse expected which was not often forthcoming on the ward simply because they didn't know what they were doing.

CONCLUSION

The findings of this study demonstrate that these ward-nurses found themselves in a difficult situation with trying to understand of the needs of the post-intensive care patient. A lack of support, a lack of education and an increased workload made this situation hard. One possible solution is the development and evaluation of a critical care outreach team to support ward-based decision-making. Combined with formal training and education around the acutely ill and /or the deteriorating patient would be a positive step forward.

IMPLICATIONS FOR CLINICAL PRACTICE

The post-intensive care patient poses significant challenges to ward nurses unfamiliar with the level of care they require. Unlike intensive care unit nurses whose focus is on survival and preventing deterioration, the ward nurse's attention is meeting the activities of daily living and progressing the patient's rehabilitation. One of the major obstacle experienced was at handover and the transferring of responsibility where the information conveyed was overly complex and to the ward nurse mostly irrelevant. For this, critical nurses must improve their proficiency at handover so that information is tailored to the needs of the ward environment. One way would be the development of a intensive care unit/Ward handover tool developed collaboratively so as maximise the priorities of care and improve patient outcome.

Sleep during and following critical illness: A narrative review

Sleep is a complex process influenced by biological and environmental factors. Disturbances of sleep quantity and quality occur frequently in the critically ill and remain prevalent in survivors for at least 12 mo. Sleep disturbances are associated with adverse outcomes across multiple organ systems but are most strongly linked to delirium and cognitive impairment. This review will outline the predisposing and precipitating factors for sleep disturbance, categorised into patient, environmental and treatment-related factors. The objective and subjective methodologies used to quantify sleep during critical illness will be reviewed. While polysomnography remains the gold-standard, its use in the critical care setting still presents many barriers. Other methodologies are needed to better understand the pathophysiology, epidemiology and treatment of sleep disturbance in this population. Subjective outcome measures, including the Richards-Campbell Sleep Questionnaire, are still required for trials involving a greater number of patients and provide valuable insight into patients’ experiences of disturbed sleep. Finally, sleep optimisation strategies are reviewed, including intervention bundles, ambient noise and light reduction, quiet time, and the use of ear plugs and eye masks. While drugs to improve sleep are frequently prescribed to patients in the ICU, evidence supporting their effectiveness is lacking.

Factors contributing to poor sleep in critically ill patients: A systematic review and meta-synthesis of qualitative studies

OBJECTIVE

To examine the causes of poor sleep in critically ill patients from nurses' experiences.

REVIEW METHODOLOGY

A meta-synthesis following the Enhancing Transparency in Reporting the Synthesis of Qualitative Research statement was conducted. Articles were searched systematically in the CINAHL, MEDLINE and Embase databases up to January 2020. Study selection and data extraction were performed by two authors working independently. Included articles were critically evaluated by both authors using the Critical Appraisal Screening Programme tool.

FINDINGS

The meta-synthesis resulted in four analytical themes: (1) Inherent factors of critical illness, (2) Lack of implementation of evidence-based practice, (3) Lack of relational collaboration, (4) Hospital organisation and culture.

CONCLUSION

This literature review indicates that promoting critically ill patients' sleep is difficult. Evidence-based interventions should be implemented into practice in order for nurses to be able to meet the patients' needs and improve sleep. Furthermore, the team surrounding the patient must have support from the health care organisation, and a culture change is necessary to improve communication between them to reach a shared goal to improve critically ill patients' sleep.

Can hypnosis and virtual reality reduce anxiety, pain and fatigue among patients who undergo cardiac surgery: a randomised controlled trial

Background

Different non-pharmacological techniques, including hypnosis and virtual reality (VR) are currently used as complementary tools in the treatment of anxiety, acute and chronic pain. A new technique called virtual reality hypnosis (VRH), which encompasses a combination of both tools, is regularly used although its benefits and underlying mechanisms remain unknown to date. With the goal to improve our understanding of VRH combination effects, it is necessary to conduct randomised and controlled research trials in order to understand their clinical interest and potential benefits.

Methods

Patients (n = 100) undergoing cardiac surgery at the Liège University Hospital will be randomly assigned to one of four conditions (control, hypnosis, VR or VRH). Each patient will receive two sessions of one of the techniques: one the day before the surgery and one the day after. Physiological assessments will be made on the monitor and patients will rate their levels of anxiety, fatigue, pain, absorption and dissociation.

Discussion

This study will help to expand knowledge on the application of virtual reality, hypnosis and VRH in the specific context of cardiac and intensive care procedures, and the influence of these non-pharmacological techniques on patient’s anxiety, fatigue, pain and phenomenological experience.

Trial registration

ClinicalTrials.gov: NCT03820700. Date registered on 29 January 2019.

Study recruitment date: October 6, 2018. Study anticipated completion date: December 28, 2020.

Impact of a Nurse Intervention to Improve Sleep Quality in Intensive Care Units: Results From a Randomized Controlled Trial

BACKGROUND

Patients of adult intensive care units (ICUs) often suffer from a lack of sleep. Reducing anxiety by promoting adaptation to the ICU prior to admission may be an appropriate way to increase sleep quality.

OBJECTIVE

The aim of this study was to evaluate the impact on sleep quality of a brief nurse intervention.

METHODS

This was a pilot randomized controlled trial in Spain. Forty patients admitted in hospital for valve cardiac surgery were randomly allocated to (1) control group (n = 20), receiving usual care, and to (2) experimental group (EG, n = 20), receiving a nurse intervention the day before surgery and admission in the ICU. The intervention was based on Roy Adaptation Model. A trained nurse anticipated the stressful stimulus to patients in order to develop functional adaptive behaviors. A set of photographs and videos was used to illustrate the environment and assistance in the ICU. Sleep quality in the ICU was measured with the Richards-Campbell Sleep Questionnaire and usual sleep quality with the Pittsburgh Sleep Quality Index.

RESULTS

After the intervention, sleep quality was lower in the EG compared with the control group (-4 points in Richards-Campbell Sleep Questionnaire, P = .69). Adjustment for main confounders led this reduction to -1.9 points (P = .87) among patients in EG. Stratified analyses shown a positive impact for people who usually slept well (+5.2 points, P = .77), but negative for those who had previous poor sleep quality (-20.0 points, P = .24).

CONCLUSION

A nurse intervention prior to ICU admission did not increase patients' sleep quality. In addition, the intervention could have incremented anxiety over the patients who used to sleep poorly at their homes.

Patient and family satisfaction levels in the intensive care unit after elective cardiac surgery: study protocol for a randomised controlled trial of a preoperative patient education intervention

INTRODUCTION

Patients and their families are understandably anxious about the risk of complications and unfamiliar experiences following cardiac surgery. Providing information about postoperative care in the intensive care unit (ICU) to patients and families may lead to lower anxiety levels, and increased satisfaction with healthcare. The objectives of this study are to evaluate the effectiveness of preoperative patient education provided for patients undergoing elective cardiac surgery.

METHODS AND ANALYSIS

100 patients undergoing elective coronary artery bypass graft, with or without valve replacement surgery, will be recruited into a 2-group, parallel, superiority, double-blinded randomised controlled trial. Participants will be randomised to either preoperative patient education comprising of a video and ICU tour with standard care (intervention) or standard education (control). The primary outcome measures are the satisfaction levels of patients and family members with ICU care and decision-making in the ICU. The secondary outcome measures are patient anxiety and depression levels before and after surgery.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Joint Chinese University of Hong Kong-New Territories East Cluster Clinical Research Ethics Committee (reference number CREC 2015.308). The findings will be presented at conferences and published in peer-reviewed journals. Study participants will receive a 1-page plain language summary of results.

TRIAL REGISTRATION NUMBER

ChiCTR-IOR-15006971.

Cardiovascular Surgery Patients: Intensive Care Experiences and Associated Factors

PURPOSE

The purpose of this study was to determine the intensive care unit (ICU) experiences of cardiovascular surgery (CS) patients and to define the associations between their ICU experiences and related factors.

METHODS

The study used a descriptive design. In total, 106 CS patients were interviewed at least 24 hours after discharge from an ICU in an educational research hospital in Ankara, Turkey between January and July 2012. Data were collected using the Intensive Care Experience Scale (ICES), a sociodemographic and clinical characteristics data form and two open-ended questions inquiring about smells and light. Statistical analyses were conducted using SPSS 15.0.

RESULTS

The patients were moderately aware of their ICU environments, partly recalled their ICU experiences, highly recollected frightening experiences, and expressed good satisfaction with care. Age, education, marital status, and pain were associated with ICU experiences. Patients who sensed smell had higher scores of frightening experiences than those who did not. Patients who were annoyed with excessive light reported less satisfaction with care than those who were not.

CONCLUSIONS

The results suggest that measuring the patients' characteristics and environmental factors may be beneficial for healthcare teams to improve the recovery of CS patients in the ICU.

'Providing good and comfortable care by building a bond of trust': nurses views regarding their role in patients' perception of safety in the intensive care unit

AIMS AND OBJECTIVES

To describe and understand intensive care unit (ICU) nurses' views regarding their role in ICU patients' perception of safety.

BACKGROUND

Feeling safe is an important issue for ICU patients. Not feeling safe may result in adverse effects including traumatic experiences, having nightmares and feeling depressed. Nursing care plays a major role in patients' perception of safety. However, it is unknown whether ICU nurses are aware of this role.

DESIGN

A grounded theory approach following Corbin and Strauss.

METHODS

A total of 13 participants were included in the study following maximum variation sampling, by selecting ICU nurses who differed in gender, age, work experience as registered ICU nurse, and were employed in different IC units. In-depth interviews were performed using open-ended questions guided by a topic list with broad question areas. Data collection and analysis were executed during an iterative process.

RESULTS

The core category, building a bond of trust to provide good and comfortable care, arose from four main categories: explaining and informing ICU patients, using patients' family bond, ICU nurses' attitudes and expertise, and creating physical safety.

CONCLUSION

The ICU nurses stated that they were not explicitly aware of ICU patients' perception of safety, but that they strived to provide good and comfortable care, through building a bond of trust with their patients. According to the nurses, a bond of trust is essential for patients to feel safe in the ICU.

RELEVANCE TO CLINICAL PRACTICE

The importance of feeling safe in ICU patients should be addressed within the education and clinical practice of ICU nurses, to ensure that they become aware of ICU patients' perception of safety.

Feeling safe during an inpatient hospitalization: a concept analysis

AIM

This paper aims to explore the critical attributes of the concept feeling safe.

BACKGROUND

The safe delivery of care is a high priority; however; it is not really known what it means to the patient to 'feel safe' during an inpatient hospitalization. This analysis explores the topic of safety from the patient's perspective.

DESIGN

Concept analysis.

DATA SOURCES

The data bases of CINAHL, Medline, PsychInfo and Google Scholar for the years 1995-2012 were searched using the terms safe and feeling safe.

METHODS

The eight-step concept analysis method of Walker and Avant was used to analyse the concept of feeling safe. Uses and defining attributes, as well as identified antecedents, consequences and empirical referents, are presented. Case examples are provided to assist in the understanding of defining attributes.

RESULTS

Feeling safe is defined as an emotional state where perceptions of care contribute to a sense of security and freedom from harm. Four attributes were identified: trust, cared for, presence and knowledge. Relationship, environment and suffering are the antecedents of feeling safe, while control, hope and relaxed or calm are the consequences. Empirical referents and early development of a theory of feeling safe are explored.

CONCLUSION

This analysis begins the work of synthesizing qualitative research already completed around the concept of feeling safe by defining the key attributes of the concept. Support for the importance of developing patient-centred models of care and creating positive environments where patients receive high-quality care and feel safe is provided.

"The button": initiating the patient-nurse interaction

Patient-nurse interactions are foundational to care that is desired by patients. Evidence about patient-initiated interactions with nurses is scant and little focus has been placed on the meaning to patients of ways to call for help when needed. The purpose of this secondary analysis was to provide a more intensive focus on initiative, one of four categories identified in a grounded theory study related to the perception of feeling safe in intensive care. Of 10 participants, a subset of 9 participant interviews was included in this analysis. Participants perceived "the button" was a way to initiate interaction with a nurse and to get the help they might need "right now." This report emphasizes the importance of nurse call lights to patients and contributes to evidence focused on the meaning for patients of initiating interaction with nurses. Findings have important implications for care quality and nurse education.

Sleep deprivation in critical illness: its role in physical and psychological recovery

Critically ill patients frequently experience poor sleep, characterized by frequent disruptions, loss of circadian rhythms, and a paucity of time spent in restorative sleep stages. Factors that are associated with sleep disruption in the intensive care unit (ICU) include patient-ventilator dysynchrony, medications, patient care interactions, and environmental noise and light. As the field of critical care increasingly focuses on patients' physical and psychological outcomes following critical illness, understanding the potential contribution of ICU-related sleep disruption on patient recovery is an important area of investigation. This review article summarizes the literature regarding sleep architecture and measurement in the critically ill, causes of ICU sleep fragmentation, and potential implications of ICU-related sleep disruption on patients' recovery from critical illness. With this background information, strategies to optimize sleep in the ICU are also discussed.

Older adults' perceptions of feeling safe in an intensive care unit

AIM

This paper is a report of a study of older adults' perceptions of feeling safe in an intensive care unit.

BACKGROUND

Significant ageing of the world population is expected. Correspondingly, there is a growing global urgency for healthcare systems to prepare for the increased number of older adults who will require intensive care. Although patients have recounted situations in which feeling safe was essential to their experience, there is little empirical evidence about feeling safe for older adults in intensive care.

METHOD

In 2008, 10 older adults who suffered unexpected critical health events and who were admitted to intensive care units were recruited for this grounded theory study. Participants were interviewed after transferring to an intermediate care unit and again after discharge. They were asked to reflect upon and discuss their experiences of feeling safe in intensive care.

FINDINGS

Participants' actual and expected interaction with intensive care nurses was essential to their perceptions of feeling safe. Four main categories were identified as requisite to interaction with nurses: proximity, oversight, predictability and initiative. A substantive grounded theory of feeling safe for older adults in intensive care is presented.

CONCLUSION

Nurses must present themselves as accessible so patients perceive that they can initiate interaction with a qualified nurse. Patients must also see that nurses are monitoring them and believe that the nurses will help them if they experience a critical health event while in the intensive care unit.

Patient and nurse perceptions of stressors in the intensive care unit

The objective of the study was to determine the perceptions of a group of patients on intensive care units' (ICUs) stressors and the perceptions of nurses on ICU patients' stressors in Turkey, and compare the differences in patients' and nurses' perception of the stressors in ICUs. In this descriptive study, 155 patients who were admitted to medical or surgical ICUs and 152 nurses who are employed in the same units of two training and research hospitals in Turkey were enrolled in this study. The ICU Environmental Stressor Scale (ICUESS) was used to determine intensive care stressors. According to total ICUESS mean scores, patients (91.41 ± 34.91) perceived significantly less stress than the ICU nurses (133.23 ± 32.20) perceived them to have. Both patients and nurses ranked 'fear of death' as the greatest stressor. Physiological stressors were identified as the most important stressors by both patients and nurses. Patients and nurses in medical ICUs were more affected by stressors than their counterparts in surgical ICUs. Patients with unplanned or emergency admissions perceived higher stress than that of patients with planned admissions. Several factors could help reduce these stressors, such as having familiar arrangements, humane ICU environment, individual patient assessments and appropriate nursing interventions.

Stressors in the ICU: a comparison of patients' and nurses' perceptions

AIMS AND OBJECTIVES

The aim of the study was to compare the stressors as perceived by patients in an intensive care unit (ICU) against those of nurses on the basis of their perceptions of patients' stressors.

BACKGROUND

Getting admitted to an ICU is viewed as a stressful event by patients. However, numerous studies have indicated that nurses do not always accurately perceive the stressors of their clients. Therefore, it is important for nurses to know what seems most stressful from the patients' perspective so that appropriate nursing measures can be directed towards minimising such stressors.

DESIGN

Survey.

METHODS

As a convenience sample, 60 patients and 54 critical care nurses were recruited. The Intensive Care Unit Stressor Questionnaire (Chinese) (ICU-CSQ) was used to collect the perceptions of stressors by the patients. Nurses were also asked to rate the items in the said questionnaire according to how they believe patients would rate them.

RESULTS

In every comparison, nurses evaluated the items to be significantly more stressful than patients did. Overall perceived stress levels of nurses were also significantly higher than those of their patients (z = -8.78, p < 0.001).

CONCLUSIONS

Nurses tended to rate the items as more stressful than did the patients, perhaps over-emphasising the stressful nature of the ICU. The findings also highlight the importance of cultural beliefs on the perceived stress levels among the Chinese population.

RELEVANCE TO CLINICAL PRACTICE

Findings in this study have strong implications in clinical practice, especially in a critical care setting. Nurses must attempt to identify and endeavour to cope with the situations that patients listed as most stressful. Moreover, attention must be drawn towards measures aimed at relieving the stress of patients by taking into account their cultural values so that culture-specific interventions for reducing their stress can be established.

Patient perception of environmental and nursing factors contributing to sleep disturbances in a neurosurgical intensive care unit

Many factors may affect sleep in the neurosurgery intensive care unit (NSICU), including therapeutic and diagnostic procedures, medications, the underlying disease process, and noise generated in NSICU. This study was aimed to determine the factors and nursing interventions, which affect the patients' sleep in NSICU, and to ascertain future descriptive research studies in nursing. The sample consisted of 84 voluntary patients hospitalized at a university hospital. They were consecutively asked to fill out a questionnaire in face-to-face interviews, and on the same day they were transferred out of the NSICU to a neurosurgical ward. Sixty-six patients (78.6%) experienced sleep disturbances. In those patients, being kept immobile (63.6%) and being in a noisy environment (57.6%) were the factors, which most frequently disturbed sleep. Likewise, the nursing interventions were found to have profound influences on patients' sleep; namely, being asked to move an arm/leg or to keep them in the same position for neurological diagnostic reasons (43.9%), and being asked questions to determine the level of consciousness (40.9%) were identified as the common sleep disturbance factors. In conclusion, immobility, environmental noise factors, and the disturbances from implementing the nursing interventions should not be ignored. Sleep disturbance in NSICU should be addressed on the multidisciplinary care plan and in health team conference, and care should be planned to assure good quality of patients' sleep. Nurses, physicians, nursing and medical students should establish and evaluate the combined interventions required for neurological assessment to decrease the negative effects of various factors on patients' sleep.

Preoperative information for ICU patients to reduce anxiety during and after the ICU-stay: protocol of a randomized controlled trial [NCT00151554]

Background

According to current evidence and psychological theorizing proper information giving seems to be a promising way to reduce patient anxiety. In the case of surgical patients, admission to the intensive care unit (ICU) is strongly associated with uncertainty, unpredictability and anxiety for the patient. Thus, ICU specific information could have a high clinical impact. This study investigates the potential benefits of a specifically designed ICU-related information program for patients who undergo elective cardiac, abdominal or thoracic surgery and are scheduled for ICU stay.

Methods/Design

The trial is designed as a prospective randomized controlled trial including an intervention and a control group. The control group receives the standard preparation currently conducted by surgeons and anesthetists. The intervention group additionally receives a standardized information program with specific procedural, sensory and coping information about the ICU.

A measurable clinical relevant difference regarding anxiety will be expected after discharge from ICU. Power calculation (α = 0.05; β = 0.20; Δ = 8.50 score points) resulted in a required sample size of N = 120 cardiac surgical patients (n = 60 vs. n = 60). Furthermore, N = 20 abdominal or thoracic surgical patients will be recruited (n = 10 vs. n = 10) to gain insight to a possible generalization to other patient groups.

Additionally the moderating effect of specific patient attributes (need for cognition, high trait anxiety) will be investigated to identify certain patient groups which benefit most.

Discussion

The proposed study promises to strengthen evidence on effects of a specific, concise information program that addresses the information needs of patients scheduled for ICU stay.

Liver transplant patients: their experience in the intensive care unit. A phenomenological study

BACKGROUND

The nurses' knowledge of patients' experiences contributes to gaining a deeper understanding of their health process, which will help to provide a better foundation for nursing care. The patients' experiences in the intensive care unit are singular; liver transplant patients constitute a specific group, because generally their admission to the intensive care unit marks the first step towards recovery of their health after a process in which they have lived in fear because their illness was reaching a more or less terminal stage.

AIM

To describe the liver transplant patient's experience in the intensive care unit.

DESIGN

Phenomenological descriptive qualitative study.

METHOD

In-depth interviews were carried out with a sample of 10 patients. The interviews were audiotaped and transcribed verbatim. The transcripts were analyzed using the method devised by Giorgi and modified by Baker.

RESULTS

After the data were analyzed, a general description emerged, which includes five themes reflecting the essence of what this group of patients experienced: preconceived ideas marked the way they approached transplant; captured impressions of the intensive care unit's environment and experienced sensations; their perception of the caring behaviour of the nursing staff; support from the social environment (family) and religious beliefs; and their preconceived idea of the intensive care unit contrasted with their lived experience.

CONCLUSION

This research enabled us to gain in-depth knowledge of the liver transplant patient's lived experience of the intensive care unit. Nurses can optimize the nursing care plan for this group of patients based on these results.

RELEVANCE TO CLINICAL PRACTICE

Awareness of the importance that these participants gave to discomfort caused in their basic needs should lead nurses to pay special attention to the nursing interventions to help with these needs. As a result of this research, nurses and other professionals in the intensive care unit know that patients have an immediate sense of positive change. This enables us to reinforce this perception, reminding them frequently that they have already had their transplant and they are progressing well, thereby aiding their recovery. With regard to the social support of liver transplant patients, nurses must facilitate the presence of family members at the patient's bedside, as participants stated that the only support they needed was that of their family.

Perception of stressors by patients and nurses of critical care units in Hong Kong

The frightening experience in critical care units, whether it be associated with the disease process or related to the critical care environment, has an important impact on clients' recovery and rehabilitation. A comparative descriptive study was conducted in the critical units of two major hospitals in Hong Kong to assess the perception of stressors by patients and nurses. A Chinese version of the Intensive Care Unit Environmental Stressor Scale (ICUESS) was used. Significant similarities and differences were noted between patients and nurses on their perceptions of stressors in the critical care environment. Critical care nurses, apart from maintaining their efforts to minimize the negative effects of the stressful critical care environment, needed to equally focus on the patients' psychological needs through measures in re-establishing patients' self-control and minimizing the emotional stress.

Transformations of self: a phenomenological investigation into the lived experience of survivors of critical illness

Based on the hermeneutical, phenomenological perspective, this study explored the lived experience of individuals with a past hospitalization in an intensive care unit, with focus on their dreams. The purpose was to explore how it is to have been critically ill. Dreams are the language of the unconscious and can symbolically convey meanings. Eight participants recounted their experiences with critical illness through semi-structured phenomenological interviews and dream-telling. An interplay between the 'factual-external' world and the 'internal' world appeared to be the basis of their perception of the situation. Participants' narratives were immensely rich in symbols of transformation, transcendence and rebirth. Transformations in perception, in lived-body, and in lived time and space were some of the themes emerging as part of both conscious and dreaming experiences. Attitudes towards death were altered, and elements of heightened spirituality were evident in the aftermath of critical illness. Critical illness was conceptualized as a 'cocooning phase' leading to transformation of self, spiritual arousal and personal growth. Nurses may be able to alleviate suffering by supporting this process while in the ICU, as well as after discharge.

[Patients with liver transplantation: their experience in the intensive care unit. Phenomenological study]

Nurses' knowledge of patients' experiences undoubtedly contributes to a greater understanding of the health process and provides a better basis for nursing acts. The aim of this study was to describe the experiences of patients with liver transplantation in the intensive care unit (ICU). The design of this qualitative study was phenomenological and descriptive. The study was performed in a sample of 10 patients who were interviewed in detail. A tape recording was made of the interview. The recordings were transcribed verbatim and were analyzed using the method of Giorgi (1985), modified by Baker in 1994. The data were analyzed and a general description was made, which included five aspects reflecting the essence of the patients' experiences: the patients arrived at the hospital with certain attitudes and beliefs; certain impressions of the atmosphere in the ICU and sensations experienced were notable; the patients experienced that they were receiving scientific and humanistic "care"; they found support in the social environment (family) and in religious beliefs, and their preconceived idea af the ICU contrasted with their experience. This study provides detailed information of the experiences of patients with liver transplantation in the ICU. The results can be used to optimize certain acts included in these patients' nursing care plans.