Patients' recollections of critical care

The effect of provision of information on serum cortisol in patients transferred from the coronary care unit to the general ward: A randomised controlled trial

BACKGROUND AND AIM

Patients' transfer from coronary care units to general wards is a main source of anxiety for patients. Transfer anxiety is due to either lack of patients' knowledge or inadequacy of transfer-related information to patients. This study aimed to evaluate the effect of provision of information on the serum cortisol level, as an indicator of anxiety, in patients transferred from the coronary care unit to the general ward.

METHODS

This pretest-posttest randomised clinical trial was conducted on fifty patients transferred from coronary care units to general wards. Patients were selected using a purposeful sampling method and randomly were allocated to control and intervention groups. After taking blood samples for a baseline cortisol measurement, the patients in the control group received routine verbal transfer-related information. The patients in the intervention group were provided with an educational pamphlet consisting of textual and visual data about patients' transfer, continuity of care and the target general ward. The second and the third blood samples were taken for a cortisol measurement half an hour after informing the patients about the transfer order and half an hour after entrance to the general ward, respectively. Descriptive and inferential statistics via the SPSS software v. 21 was used for data analysis.

RESULTS

No statistically significant differences were reported between the groups in terms of demographic characteristics (p > 0.05). The serum levels of cortisol in the intervention group decreased from 40.16 (microgram per decilitre) at the baseline to 36.52 and 34.34 at the second and the third measurement time points, respectively. Conversely, the serum levels of cortisol in the control group increased from 37.48 at the baseline to 40.52 and 41.52 at the second- and the third-time points, respectively. While no statistically significant difference was reported between the groups in the baseline serum level of cortisol, between-group differences were statistically significant at the second- and the third-time points (p < 0.05).

CONCLUSION

Provision of transfer-related information can reduce transfer anxiety among patients, that should be transferred from coronary care units to general wards.

Satisfaction Domains Differ between the Patient and Their Family in Adult Intensive Care Units

Background. Patients' and family's satisfaction data from the Asian intensive care units (ICUs) is lacking. Objective. Domains between patient and family satisfaction and contribution of each domain to the general satisfaction were studied. Method. Over 3 months, adult patients across 4 ICUs staying for more than 48 hours with abbreviated mental test score of 7 or above and able to understand English and immediate family members were surveyed by separate validated satisfaction questionnaires. Results. Two hundred patients and 194 families were included in the final analysis. Significant difference in the satisfaction scores was observed between the ICUs. Patients were most and least satisfied in the communication (4.2 out of 5) and decision-making (2.9 out of 5) domains, respectively. Families were most and least satisfied in the relationship with doctors (3.9 out of 5) and family's involvement domains (3.3 out of 5), respectively. Domains contributing most to the general satisfaction were the illness management domain for patients (β coefficient = 0.44) and characteristics of doctors and nurses domain for family (β coefficient = 0.45). Discussion. In an Asian ICU community, patients and families differ in their expectations and valuations of health care processes. Health care providers have difficult tasks in attending to these different domains.

Patient Experiences Following Cardiothoracic Surgery: An Interview Study

Background: Numerous studies have investigated patient outcomes of cardiac surgery, including some examining health-related quality of life. While these studies have provided some insight into patients' physical function, social abilities and perceived quality of life, studies examining the experiences of individuals recovering from cardiac surgery have received only limited investigation.

Aims: This paper presents a thematic analysis of interviews conducted with patients recovering from cardiothoracic surgery, about their memories and experiences of hospital and recovery post-hospital discharge.

Methods: Using an exploratory qualitative approach, eight participants were interviewed 6 months following their surgery. Transcripts of interviews were examined using a content analysis approach, with open coding of text and categorising of similar concepts into themes.

Findings: Participants reported varying degrees of pain and physical dysfunction during their recovery from surgery and some had still not returned to optimal function. Seven themes emerged from the data: impressions of ICU; comfort/discomfort; being sick/getting better; companionship/isolation; hope/hopelessness; acceptance/apprehension; and life changes. A number of the themes were constructed as a continuum, with participants often demonstrating a range of views or experiences. Many had little or no memory of their stay in the intensive care unit, although others had vivid recollections. Their impressions of hospital were mostly positive, although many experienced fear, apprehension, and mood disturbances at some time during their recovery. Most participants recalled being sick, reaching a turning point, and then getting better. Many participants reported a change in life view since their recovery from surgery.

Conclusions: Attention to specific areas of patient orientation, education and support was identified to facilitate realistic expectations of recovery. In addition, some form of systematic follow-up that focuses on patient recovery in terms of both physical and psychological function is important.

Intensive care patients' perceptions of how their dignity is maintained: A phenomenological study

AIM

The aim of the study was to acquire knowledge of what contributes to maintaining and promoting the dignity of intensive care patients.

METHOD

The study takes a phenomenological approach, and the method of data collection is qualitative research interviews. The participants consist of seven former intensive care patients. The analysis was carried out by means of Giorgi's phenomenological analysis strategy.

FINDINGS

Being seen and heard and having one's wishes and needs attended to are parts of dignified care. Personal and individual nursing was essential, as well as the extra involvement beyond what was expected. Being helpless and having to be cared for was unpleasant and degrading. The experience of being unable to speak could cause demeaning situations. Being met with respect was the essence of having one's dignity maintained and promoted. The sense of being treated as an object was the essence of experiences that inhibited dignity.

CONCLUSION

The findings indicate that the intensive care patients' experience of having their dignity maintained in an intensive care unit is good, despite a high-tech, busy environment. There is also potential for improvement in several areas. Awareness, moral integrity and demeanour are central to dignified patient care from the perspective of intensive care patients.

Distress due to delirium experience

BACKGROUND

Very few studies have evaluated the level of distress due to the experience of delirium in patients who have recovered from delirium.

METHODOLOGY

Fifty-three patients were rated on Delirium Rating Scale-Revised-98 at baseline and were again evaluated on Delirium Experience Questionnaire after recovery for level of distress due to the experience of delirium.

RESULTS

The mean age of patients was 45.58 (S.D. 19.06) years. Only 15 patients (28.3%) remembered themselves to be confused and rest had no recollection of the same. Those who could remember their experience had moderate (n = 4; 26.7%), severe (n = 6; 40.0%) and very severe (n = 5; 33.3%) level of distress. Of those who could not remember their delirium experience, most of them had moderate (n = 17; 44.7%) to severe (n = 10; 26.3%) distress. Those who remembered their experience in general described it as a state of fearfulness (n = 8), anxiety (n = 4) confusion and feeling strange (n = 7). Other experiences which were recollected were those of visual hallucinations and illusions.

CONCLUSION

Overall experience of delirium is distressing for the patients. Most of the patients (those who remembered or who were not able to remember) experienced at least moderate level of distress.

Revisiting caring science: some integrative ideas for the 'head, hand and heart' of critical care nursing practice

AIM

This paper introduces the notion of 'Caring science' as a way to delineate and develop particular kinds of knowledge relevant to caring practices in critical care.

RELEVANCE FOR PRACTICE

Firstly, one particular development of person centred care, lifeworld led care is offered. Its relevance for critical care nursing is analysed by pointing to examples of studies which describe temporality, spatiality, intersubjectivity and embodiment and how they may manifest with reference to the person as 'body object/body subject' and the matter of technology in critical care environments. Secondly, by use of an imagined practice scenario, the challenge of expanding our traditional notions of evidence to encompass ways of knowing that are more intimately embodied and practice related is discussed. Such knowledge, referred to as 'embodied relational understanding' is particularly relevant to a conception of caring for persons' in a holistic way.

CONCLUSION

The paper concludes by pointing to the potential for caring science, grounded in lifeworld led care, to offer some integrating ideas that legitimate the full range of resources, 'head', 'hand' and 'heart', that nurses can draw upon in everyday holistic critical care practice.

Symptoms experienced by intensive care unit patients at high risk of dying

OBJECTIVE

To provide a focused, detailed assessment of the symptom experiences of intensive care unit patients at high risk of dying and to evaluate the relationship between delirium and patients' symptom reports.

DESIGN

Prospective, observational study of patients' symptoms.

SETTING

Two intensive care units in a tertiary medical center in the western United States.

PATIENTS

One hundred seventy-one intensive care unit patients at high risk of dying.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were interviewed every other day for up to 14 days. Patients rated the presence, intensity (1 = mild; 2 = moderate; 3 = severe), and distress (1 = not very distressing; 2 = moderately distressing; 3 = very distressing) of ten symptoms (that is, pain, tired, short of breath, restless, anxious, sad, hungry, scared, thirsty, confused). The Confusion Assessment Method-Intensive Care Unit was used to ascertain the presence of delirium. A total of 405 symptom assessments were completed by 171 patients. Patients' average age was 58 ± 15 yrs; 64% were males. Patients were mechanically ventilated during 34% of the 405 assessments, and 22% died in the hospital. Symptom prevalence ranged from 75% (tired) to 27% (confused). Thirst was moderately intense, and shortness of breath, scared, confusion, and pain were moderately distressful. Delirium was found in 34.2% of the 152 patients who could be evaluated. Delirious patients were more acutely ill and received significantly higher doses of opioids. Delirious patients were significantly more likely to report feeling confused (43% vs. 22%, p = .004) and sad (46% vs. 31%, p = .04) and less likely to report being tired (57% vs. 77%, p = .006) than nondelirious patients.

CONCLUSIONS

Study findings suggest that unrelieved and distressing symptoms are present for the majority of intensive care unit patients, including those with delirium. Symptom assessment in high-risk intensive care unit patients may lead to more focused interventions to avoid or minimize unnecessary suffering.

Qualitative analysis of patients' intensive care experience during mechanical ventilation

AIM

To understand patients' intensive care experience while receiving mechanical ventilation in intensive care units.

BACKGROUND

The mechanically ventilated patient's experience in the intensive care unit is unique. Notably lacking are international studies on patients' experience, particularly those living in Asia. A better understanding of patients' experience is needed for nurses to develop approaches to take care of these patients.

DESIGN

A phenomenological approach formed by the ideas of Heidegger was used.

METHODS

Eleven participants surviving from mechanical ventilation were interviewed in-depth. Patients were asked to describe their experience by responding to the question 'what is it like to experience mechanical ventilation treatment at an ICU?'. Giorgi's phenomenological analysis procedure was used to analyse the data.

RESULTS

Five mutually exclusive themes emerged, which were: 'being in an unconventional environment', 'physical suffering', 'psychological suffering', 'self-encouragement' and 'self-reflection'. 'Self-encouragement' and 'self-reflection' enhanced patients' self-confidence, which was beneficial to recovering.

CONCLUSION

Patient's experiences while receiving mechanical ventilation in the intensive unit were poignant and frightening.

RELEVANCE TO CLINICAL PRACTICE

Critical care nurses should place the highest priority on recognising and meeting the needs of ventilated patients in intensive care units. An intensive care unit should be a place for the patient to live as a human being; not just a place to survive.

Closing the gap: the patient-physician disconnect

This article will present the results of over 150 focus groups conducted to identify the underlying drivers of customer satisfaction in a variety of health care settings. These focus groups demonstrate that the vast majority of patients first seek to have their negative emotional state addressed and then to receive medical care. The hypothesis presented is that patients' satisfaction is based more on short-term consequences than long-term consequences (effects of treatment) because the short-term consequences involve reducing patients' negative emotions that they bring to the treatment situation. Supporting one of the key points from the literature, if initial satisfaction is low, patient compliance suffers, then treatment efficacy is reduced. Therefore, short-term satisfaction mediates long-term satisfaction.

Experiences of critically ill patients in the ICU

BACKGROUND

Experiences of critically ill patients are an important aspect of the quality of care in the intensive care (ICU).

OBJECTIVE

The aims of the study were firstly, to evaluate the perceptions of patients regarding nursing care in the ICU, and secondly, to explore patients' perceptions and experiences of ICU stay.

METHOD

A qualitative approach using a semi-structured focused interview in 11 patients was used (phase 1), followed by a quantitative approach using a self-reported questionnaire in 100 patients, 62 were returned and 50 could be evaluated (phase 2).

RESULTS

A number of themes emerged from the interviews (phase 1), although support dominated as an important key theme. This was experienced as a continuum from the feeling being supported by the nurse to not being supported. This key theme was central to each of the three categories emerging from the data pertaining to: (1) providing the seriously ill patient with information and explanation, (2) placing the patient in a central position and (3) personal approach by the nurse. The responders to the subsequent questionnaire (phase 2) predominantly experienced sleeping disorders (48%), mostly related to the presence of noise (54%). Psychological problems after ICU stay were reported by 11% of the patients, i.e. fear, inability to concentrate, complaints of depression and hallucinations.

CONCLUSIONS

Although the nurses' expertise and technical skills are considered important, caring behaviour, relieving the patient of fear and worries were experienced as most valuable in bedside critical care.

A phenomenological study of medically induced unconsciousness in intensive care

Critically ill patients who require mechanical ventilation in intensive care units (ICUs) are usually sedated with drugs such as Morphine and Midazolam in order to facilitate ventilation, relieve pain and lower metabolic demands. Participants in this research were sedated to the point of 'medically induced unconsciousness' in that they were non eye opening nor responsive to verbal directives. A purposive sample of five individuals who had experienced the phenomenon of 'medically induced unconsciousness' were interviewed indepth. These interviews were transcribed verbatim and then analysed using a Husserlian phenomenological approach. Three essences were revealed within the data, each with associated themes. These essences were utter helplessness, cognition and succour. Utter helplessness was linked to: an inability to communicate either verbally or physically; pain during procedures; a sense of threat to personal safety; depersonalisation; loss of control and a sense of loneliness. Rather than an alteration of cognition, the themes that emerged within this second essence revealed attempts by participants to understand the experiences associated with 'medically induced unconsciousness'. These themes were: dreams; dissociation of self from the physical body; time-space relatedness and chaos. The final essence to emerge was that of succour. This essence portrays some of the more positive aspects of the experience. The themes revealed were: security in the ventilator; comfort in voices; human presence; painfree and purpose. Participants in this study were experiencing many things as they lay unresponsive on their beds in the ICU. The absence of physical responses should not be misinterpreted to mean that cognitive processes are not occurring. Participants appeared to be attempting to make sense of their immediate environment through their dreams.

Good nursing care to ICU patients on the edge of life

Critically ill patients are admitted to intensive care units (ICUs) to receive advanced technological and medical treatment. Some patients seem not to benefit from the treatment, and sometimes questions are raised as to whether treatment should be withheld or withdrawn. This study was conducted using ICU nurses' experiences with the aim of acquiring a deepened understanding of what good nursing care is for these patients. The study was performed at an adult ICU in Norway, where 14 ICU female nurses were included as participants. The research design was based on interpretative phenomenology and data was collected by group interviews inspired by focus-group methodology. The participants were divided into two groups and each group was interviewed four times. Colaizzi's model was used in the process of analysis. The results show that good nursing care depended on several basic conditions: continuity, knowledge, competence and cooperation, and included clear goals to give appropriate life-saving -- or end-of-life treatment and care. Cornerstones in good nursing care were nurses' verbal communication and nurses' use of their hands. The study emphasises several consequences for future ICU nursing practice and education to enhance good nursing care to patients on the edge of life.

The views of patients and relatives of what makes a good intensivist: a European survey

OBJECTIVE

This study examined the views of adult patients and relatives about desirable characteristics of specialists in intensive care medicine (ICM) to incorporate these into an international competency-based training programme, CoBaTrICE.

DESIGN

Convenience sample of patients and relatives administered after discharge from 70 participating ICUs in eight European countries (1,398 evaluable responses). The structured questionnaire included 21 characteristics of medical competence categorised as 'medical knowledge and skills', 'communication with patients', and 'communication with relatives'. It was available in the national languages of the countries involved. Questions were rated by respondents for importance using a four-point Likert scale. Responses to open questions were also invited.

RESULTS

Most characteristics were highly rated, with priority given to medical knowledge and skills. Women were more likely to emphasise communication skills. There were no consistent regional differences. Free-text responses welcomed the opportunity to participate.

CONCLUSIONS

Patients and relatives with experience of intensive care in different European countries share similar views on the importance of knowledge, skills, decision making and communication in the training of intensive care specialists. These generic patient-centred components of training have been incorporated into the international competency-based ICM training programme, CoBaTrICE.

Cognitive sequelae in acute respiratory distress syndrome patients with and without recall of the intensive care unit

Some critically ill patients have dramatic recollections of the intensive care unit (ICU), whereas 23-50% have little or no recollection of their ICU stay. In addition, cognitive impairments are common following critical illness and ICU treatment. Little is known regarding the relationship between cognitive sequelae and ICU recall. We assessed recall of the ICU and its relationship to cognitive functioning at hospital discharge and 1 and 2 years after discharge in 70 consecutive acute respiratory distress syndrome (ARDS) patients. Seventeen patients (24%) had no recall of the ICU. Patients without ICU recall had increased rates of cognitive sequelae at hospital discharge and 1-year follow-up compared with the ICU recall group. Patients without ICU recall had a greater magnitude of cognitive impairments at hospital discharge, but not at 1- or 2-year follow-up. Profile analysis showed significant group differences in general intellectual functioning, executive function, processing speed, and spatial skills at hospital discharge, but not at 1- or 2-year follow-up. Estimated premorbid intelligence scores were inversely related to the magnitude of cognitive sequelae, suggesting greater "cognitive reserve" in patients with fewer cognitive decrements.

Percepção do estresse entre enfermeiros que atuam em Terapia Intensiva

OBJETIVO: o estudo investigou a ocorrência de estresse entre enfermeiros que atuam na assistência a pacientes críticos de uma Unidade de Cuidados Intensivos em um hospital universitário. MÉTODOS: utilizou-se um instrumento para descrição sociodemográfica da amostra e um inventário para identificar o estresse e a fase em que se encontra. RESULTADOS: a amostra foi composta por 12 enfermeiros, 91,7% do sexo feminino; 75% com carga horária de trabalho entre 10-12 horas diárias; 33,4% com tempo de formação universitária entre 5 e 10 anos. DISCUSSÃO: mais da metade dos trabalhadores (66,7%), que assiste pacientes críticos, mostrou sinais de sofrimento físico e/ou psicológico característicos da fase de resistência ao estresse. CONCLUSÃO: tais achados sugerem a necessidade de atenção a esses profissionais para que seus sintomas não evoluam para a fase de exaustão.

Patient empowerment in intensive care--an interview study

Intensive care patients often experience a lack of control, as well as inner chaos. Experiences from intensive care can continue to affect patients for a long time. Empowerment is a positive and dynamic process that focuses on people's strengths, rights and abilities. It takes on different expressions for different people in different environments and must be described by the people involved. The aim of this study was to describe patient empowerment in an intensive care situation. The study was based on open-ended interviews with 11 patients in two intensive care units. The interviews were analysed according to the empirical phenomenological psychological method. The results showed that patient empowerment in intensive care consists of strengthening and stimulating the patients' own inherent joy of life and will to fight. A positive environment that encouraged feelings of value and motivation and in which the patient felt safe, received additional care and participated as he/she wished had a positive influence.

‘Fishing with the dead’—Recall of memories from the ICU

The purpose of this study was to explore the memories of patients who had a short-term admission to the ICU, with a particular focus on dreams, nightmares and confusion. Descriptive data were collected from a target sample of 50 participants, by means of a questionnaire. Following this, eight patients who had completed and returned the questionnaire and had reported hallucinations, dreams or confusion participated in open-ended, semi-structured interviews. Analysis of the data generated by the questionnaire revealed that the most common memories of ICU were anxiety, pain, thirst and nausea. Nightmares, hallucinations and confusion were also common and were reported to be highly distressing. The transcribed interviews were subjected to a thematic analysis. The themes that emerged were, reality and unreality, blackness and colour, powerlessness and purpose, and death. Participants described horrifying paranoid delusions. It is proposed that constant reassurance and explaining every day ICU happenings may assist patients to understand what they are experiencing and loved ones may provide an important link with reality.

A qualitative study of the experiences of patients following transfer from intensive care

In nursing literature much attention has been paid to patients' experiences while in intensive care. Extensive literature exists examining the longer-term effects of critical care [Jones C, Humphris GM, Griffiths RD. Psychological morbidity following critical illness - the rationale for care after intensive care. Clinical Intensive Care 1998;9:199-205; Griffiths RD, Jones C. ABC of intensive care. Recovery from intensive care. Br Med J 1999;319:417-429]. There is an apparent scarcity of data examining patients' experiences immediately following discharge to wards. A Husserlian phenomenological approach was utilised to gain some understanding of the experience of patients following transfer from intensive care. Ten patients selected purposively comprised the sample. Interviews were performed on the wards 3-5 days following transfer from intensive care. Data was analysed utilising () [Colaizzi PF. Psychological Research as the phenomenologist views it. In: Valle R, King M, editors. Alternatives for psychology. New York: Oxford University Press; 1978. p. 48-71] procedural approach to phenomenological interpretation and analysis. Three major themes emerged: physical response, psychological response and provision of care. These provide a possible framework for patient assessment. Implications for future practice and study are discussed.

The Stress Response, Psychoneuroimmunology, and Stress Among ICU Patients

Multiple stressors, physical and psychological, may beset intensive care unit patients. This article opens with a description of the stress cascade and its connection with immunity. Examples of intensive care unit stressors follow, along with various proposed interventions to reduce psychological stress among intensive care unit patients. Although researchers have yet to establish that such interventions will positively impact immune function, they are an essential component of compassionate and holistic care.

Memories of intensive care and experiences of survivors of a critical illness: an interview study

Recovery from a critical illness can be a complex and protracted process. It is known that for some, health-related quality of life (HRQOL) does not return to pre-illness levels for many months, and in some disease processes this may be longer. This study was undertaken as part of a larger project examining the pain and health status of survivors of a critical illness. The aims of the qualitative aspect of the study were to examine the participants' memories of intensive care and hospitalisation at 6 months post-discharge, and to explore the impact of the critical illness experience on their recovery. Purposive sampling was used to enable rich descriptions of the experience of recovery from those patients best able to articulate their experiences. Three common themes were found with our six participants: recollections, responses, and comfort/discomfort. Recovery from their critical illness continued to affect the participants and carers, some profoundly so. Better integration of services and continued support is required for survivors of a critical illness up to and beyond 6 months.

Optimum sedation and analgesia in critical illness: we need to keep trying

Many studies have documented patients' distressing recollections of the intensive care unit (ICU). The study by van de Leur and colleagues, conducted in a group of surgical ICU patients with moderate severity of sickness, found that the frequency of such unpleasant memories was increased in those able to recall factual information about their stay in the ICU. The study did not include sedation scoring but it did use a simple tool to assess factual recall. This tool appeared reliable and could be easily applied in any ICU. Previous work strongly suggests that abolishing memory of ICU by using deep sedation would not be an appropriate response to these findings. Rather, we need to work on strategies that reduce distress by improving analgesia, reducing noxious stimuli (if possible) and, potentially, using pharmacology to produce a calm patient with minimal sedation. Achieving the latter is rarely possible today but it might become possible with future drug development.

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.

Discomfort and factual recollection in intensive care unit patients

INTRODUCTION

A stay in the intensive care unit (ICU), although potentially life-saving, may cause considerable discomfort to patients. However, retrospective assessment of discomfort is difficult because recollection of stressful events may be impaired by sedation and severe illness during the ICU stay. This study addresses the following questions. What is the incidence of discomfort reported by patients recently discharged from an ICU? What were the sources of discomfort reported? What was the degree of factual recollection during patients' stay in the ICU? Finally, was discomfort reported more often in patients with good factual recollection?

METHODS

All ICU patients older than 18 years who had needed prolonged (>24 hour) admission with tracheal intubation and mechanical ventilation were consecutively included. Within three days after discharge from the ICU, a structured, in-person interview was conducted with each individual patient. All patients were asked to complete a questionnaire consisting of 14 questions specifically concerning the environment of the ICU they had stayed in. Furthermore, they were asked whether they remembered any discomfort during their stay; if they did then they were asked to specify which sources of discomfort they could recall. A reference group of surgical ward patients, matched by sex and age to the ICU group, was studied to validate the questionnaire.

RESULTS

A total of 125 patients discharged from the ICU were included in this study. Data for 123 ICU patients and 48 surgical ward patients were analyzed. The prevalence of recollection of any type of discomfort in the ICU patients was 54% (n = 66). These 66 patients were asked to identify the sources of discomfort, and presence of an endotracheal tube, hallucinations and medical activities were identified as such sources. The median (min-max) score for factual recollection in the ICU patients was 15 (0-28). The median (min-max) score for factual recollection in the reference group was 25 (19-28). Analysis revealed that discomfort was positively related to factual recollection (odds ratio 1.1; P < 0.001), especially discomfort caused by the presence of an endotracheal tube, medical activities and noise. Hallucinations were reported more often with increasing age. Pain as a source of discomfort was predominantly reported by younger patients.

CONCLUSION

Among postdischarge ICU patients, 54% recalled discomfort. However, memory was often impaired: the median factual recollection score of ICU patients was significantly lower than that of matched control patients. The presence of an endotracheal tube, hallucinations and medical activities were most frequently reported as sources of discomfort. Patients with a higher factual recollection score were at greater risk for remembering the stressful presence of an endotracheal tube, medical activities and noise. Younger patients were more likely to report pain as a source of discomfort.

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.

Leaving the intensive care unit: a phenomenological study of the patients’ experience

Discharge from intensive care (ICU), is said to pose difficulties for patients; a phenomenon referred to as "relocation stress". However, this phenomenon has not been fully examined, particularly from the critical care patients' perspective. This study, therefore, explored the lived experience of transfer from ICU to the ward. Phenomenology, based on the interpretative Heideggerian approach was used to guide the study. A purposive sample of six participants was selected. Open interviews were used to collect data. Participants were interviewed twice; once in ICU, prior to transfer, and once in the ward following transfer. The findings revealed that pre-transfer, participants were mainly accepting of their impending transfer. Participants discussed a desire for normality and identified that leaving the ICU staff was the most negative component of transfer. In the post-transfer period, findings revealed mixed feelings regarding the actual transfer. Participants were still suffering from physical complaints, which led to feelings of despondency. Differences between ICU and the ward were also highlighted. Finally, the enormity of the ICU experience appeared to have an impact post-transfer. The results of this study indicate that transfer from ICU can be problematic for some individuals. However, caution is required regarding the use of the nursing diagnosis of relocation stress without obtaining an individual perspective on experiences. Recommendations include the need for greater continuity of care for those recovering from critical illness.

Palliative care of the chronically critically ill patient

Evidence is accumulating that distressing physical and emotional symptoms are prevalent among patients with critical illness, including those requiring prolonged mechanical ventilation, and that suffering is underestimated and undertreated by caregivers. Although patients and their families rank communication as a preeminent concern, it remains deficient in process and content, even when the illness requires weeks of critical care. Strategies are available to improve symptom management and communication about appropriate goals of care. For the CCI, whose risks of death, disability, and suffering are so high, it is essential that excellent palliative care be provided along with restorative treatment in an integrated way.

Recovering From Cardiac Surgery: What Patients Want You To Know

• Background Care of cardiac surgery patients has changed substantially in the past decade, with an emphasis on streamlined procedures and shortened hospital stays. The few qualitative reports of patients’ perspectives of this experience focus primarily on physical complications and discomforts during the immediate postoperative period.

• Objective To examine patients’ perceptions of the quality of the nursing and medical care they received during their hospital stay after cardiac surgery.

• Methods Data were collected from a consecutive sample of 89 cardiac surgical patients who consented to participate in 2 telephone interviews at 1 week and 6 weeks after hospitalization. Patients responded to a single open-ended question: “What do you want your nurses and doctors to know to help them do a better job?” Thematic extraction analysis of patients’ responses was conducted by using commercially available statistical software. Extracted themes were applied to the structure-process-outcome framework of quality of care.

• Results Four major themes (and 12 subthemes) were identified: (1) being satisfied (having a positive experience, getting information), (2) not being cared for (feeling depersonalized, having expectations that did not match recovery experiences, not being listened to, experiencing unprofessional behavior by care providers, experiencing continued care needs after going home), (3) physical needs unmet (sleep, pain, complications, physical environment), and (4) informational needs unmet (needing more or different information).

• Conclusions Patients want nurses and doctors to provide a smooth transition to home, recognize the patients as individuals, prepare them honestly for their experiences with specific information, and manage pain and sleep.

The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses

We conducted a systematic examination of the experience of delirium in a sample of 154 hospitalized patients with cancer. Patients all met DSM-IV criteria for delirium and were rated with the Memorial Delirium Assessment Scale as a measure of delirium severity, phenomenology, and resolution. Of the 154 patients assessed, 101 had complete resolution of their delirium and were administered the Delirium Experience Questionnaire (DEQ-a face-valid measure that assesses delirium recall and distress related to the delirium episode). Spouse/caregivers and primary nurses were also administered the DEQ to assess distress related to caring for a delirious patient. Fifty-four (53.5%) patients recalled their delirium experience. Logistic-regression analysis demonstrated that short-term memory impairment (odds ratio [OR] = 38.4), delirium severity (OR = 11.3), and the presence of perceptual disturbances (OR = 6.9) were significant predictors of delirium recall. Mean delirium-related distress levels (on a 0-4 numerical rating scale of the DEQ) were 3.2 for patients who recalled delirium, 3.75 for spouses/caregivers, and 3.09 for nurses. Logistic-regression analysis demonstrated that the presence of delusions (OR = 7.9) was the most significant predictor of patient distress. Patients with "hypoactive" delirium were just as distressed as patients with "hyperactive" delirium. Karnofsky Performance Status (OR = 9.1) was the most significant predictor of spouse/caregiver distress. Delirium severity (OR =5.2) and the presence of perceptual disturbances (OR =3.6) were the most significant predictors of nurse distress. In conclusion, a majority of patients with delirium recall their delirium as highly distressing. Delirium is also a highly distressing experience for spouses/caregivers and nurses who are caring for delirious patients. Prompt recognition and treatment of delirium is critically important to reduce suffering and distress.

O significado cultural do cuidado humanizado em unidade de terapia intensiva: "muito falado e pouco vivido"

Este trabalho consistiu em um estudo etnográfico, cujo objetivo foi compreender o significado cultural do cuidado humanizado, na perspectiva da equipe de enfermagem que atua na Unidade de Terapia Intensiva do Hospital das Clínicas da Universidade Federal de Goiás. Para a coleta de dados, foram realizadas observações participantes e entrevistas semi-estruturadas com enfermeiros, técnicos e auxiliares de enfermagem, em seu ambiente de trabalho. Com a análise dos dados, emergiram três categorias principais que deram sentido ao significado do cuidado humanizado na UTI: cuidado Humanizado - amar ao próximo como a si mesmo; cuidado humanizado - não está presente como deveria estar; estresse e sofrimento: é preciso cuidar de quem cuida. O tema cultural foi o cuidado humanizado - muito falado e pouco vivido. Esse tema mostra a realidade do cuidar em terapia intensiva, envolvendo uma equipe de enfermagem que tem um conceito de humanização sintetizado na expressão: amar ao próximo como a si mesmo, mas que, na prática, não revela esse pensamento tão profundo.

Vulnerability and security in seriously ill patients in intensive care

The purpose of this research was to gain an understanding of the experience of being a seriously ill patient in an intensive care unit (ICU). Fourteen former patients, aged 17-71 years old, who had been in ICU 3-53 days, participated in focus group interviews 3-6 months after discharge. The focus groups met 3 times each for 1.5 hours, resulting in 13-14 hours of audiotaped discussions. The transcribed data were qualitatively analysed to identify themes representing participants' experiences. Vulnerability emerged as a central concept that captured the identified themes. The data reveal that patient vulnerability while in ICU was related to extreme physical and emotional dependency. Lack of information and depersonalizing care were associated with fear, anxiety and increased vulnerability. Lack of sleep and rest also contributed to patient fear and anxiety. Vulnerability decreased when patients were kept informed of what was occurring while in ICU, received care that was personalized to their individual needs, and when their families were present. The results of this study suggest that ICU patients' vulnerability may be decreased by the security that they experience when they are adequately informed about what is happening, and when nursing and medical care is personalized to their individual needs.

[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.

Recollection of children following intensive care

BACKGROUND AND AIMS

The recollections of critically ill children following discharge from the paediatric intensive care unit (PICU) have not previously been described. We have interviewed such children to establish the nature of their recollections.

METHODS

Children aged 4 years and above were interviewed following discharge from the PICU at the Queens Medical Centre, Nottingham, either in hospital or at home, using a semistructured interview. Their recollections were recorded and interpreted by content analysis.

RESULTS

A total of 38 interviews were carried out; 44 specific recollections were reported, the majority being neutral (60%) or positive (25%). Only 15% of recollections were negative. Negative recollections related to aspects of medical care and environmental factors. No child treated with neuromuscular blocking agents remembered any period of therapeutic paralysis.

CONCLUSIONS

Children's recollections of PICU are mainly neutral or positive. Mechanically ventilated children sedated with midazolam and morphine remember little of endotracheal intubation.

Creating a healing environment for elders

The number of elderly, both in society at large and in the critical care population, is increasing at an unprecedented rate. Critical care nurses must address how best to provide care to these elders. The authors focus on physiologic, cognitive, and psychosocial characteristics of the elderly that place them at risk for complications during their stay in critical care. The critical care environment also contributes to complications such as sleep deprivation, sensory deprivation or overload, painful procedures, and decreased social support. The critical care environment may also be a factor in facilitating delirium, common in critically ill elders. Critical care nurses can proactively help to create a healing environment for these elders by facilitating sleep, implementing strategies to reduce delirium, preventing or minimizing painful experiences, and liberalizing family visitations.

Nurse-patient communication in the intensive care unit: a review of the literature

Patient care within an intensive care unit (ICU) can be a difficult and stressful task for even the most experienced and skilled critical care nurse. Good communication between the patient, relatives and nurse is integral to quality care of the patient and should extend to the entire health-care team. This article reviews the literature on nurse-patient communication in the ICU. While numerous research studies have been completed, they are predominantly qualitative and descriptive. Recent studies have investigated the patients' perceptions and recollections of the communication that transpired between them and nurses while they were cared for within an ICU. The literature indicates that nurses communicate extremely poorly with patients, despite a high level of knowledge and skill with respect to communication. Tentative explanations of high stress levels, a preoccupation with physical care and technology, and the attraction to critical care areas of nurses with specific personality types are discussed as possible reasons for this. The need for further research into, and attempts to alleviate, this problem is clearly demonstrated.

The cardiac surgical patient's expectations and experiences of nursing care in the intensive care unit

There is an abundance of research investigating patient satisfaction. However, few studies have addressed patient satisfaction by comparing patients' expectations of nursing care with the care they actually received. This qualitative study explores both cardiac surgical patients' preconceptions and expectations of nursing care in the intensive care unit (ICU) and their actual experience of nursing care while in the unit. Data were collected using a semistructured interview technique. Interviews took place prior to admission and following discharge from ICU, and were taped and transcribed. Using thematic analysis, major and minor themes emerged from the data. The preoperative interviews revealed that participants had clear expectations of the nurse's role in ICU. They expected the nurse who cared for them to be capable, intelligent, experienced and technically adept. Further, they wanted a nurse who would be vigilant and provide them with personalised care. Participants understood they would be vulnerable and looked to the nurse to help them through this period. Post-operative interviews revealed that when participants perceived vigilance or experienced personalised care from the nurses they felt reassured and secure. However, patients also described feelings of anxiety, apprehension, fear and other unexpected experiences, notably confusion and hallucinations. Recommendations suggest that modification to pre-operative patient education programs could lead to a reduction in anxiety in the post-operative period. They also highlight the importance, to the patients, of nurse caring activities. In addition, the findings suggest a need for staff education that addresses patient anxiety and post-operative psychological disturbances.