A threat to the understanding of oneself: intensive care patients' experiences of dependency

Oral health decline in patients after stroke: a qualitative study

Introduction To develop and implement effective oral care interventions for patients after stroke, there is a need to understand the causes behind the decline in their oral health. This qualitative study was, therefore, undertaken to explore experiences and views of health service providers about the causes of oral health decline in this group of patients.Methods A purposively selected sample of healthcare service providers who work in two NHS Trusts in the North of England were interviewed utilising a semi-structured interview technique. Interviews were conducted with the assistance of a topic guide and continued until data saturation (n = 30) was reached. The constant comparative approach was used to analyse the data.Results Two major factors, perceived by the participants, were thought to cause oral health decline in patients after stroke. Post-stroke neurological deficits resulting in oral-related functional disturbances was the first. The second was the barriers leading to difficulties in performing or receiving daily oral care. These barriers were related to the patients, their service providers, or the environment in which care is being delivered.Conclusions This study described the major factors affecting the oral health of patients after stroke, which can offer a starting point for developing effective oral care interventions for them.

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

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Longing for homelikeness: A hermeneutic phenomenological analysis of patients' lived experiences in recovery from COVID-19-associated intensive care unit acquired weakness

Aims

To explore lived experiences of patients recovering from COVID‐19‐associated intensive care unit acquired weakness and to provide phenomenological descriptions of their recovery.

Design

A qualitative study following hermeneutic phenomenology.

Methods

Through purposeful sampling, 13 participants with COVID‐19‐associated intensive care unit acquired weakness were recruited with diversity in age, sex, duration of hospitalization and severity of muscle weakness. Semi‐structured in‐depth interviews were conducted from 4 to 8 months after hospital discharge, between July 2020 and January 2021. Interviews were transcribed verbatim and analysed using hermeneutic phenomenological analysis.

Results

The analysis yielded five themes: ‘waking up in alienation’, ‘valuing human contact in isolation’, ‘making progress by being challenged’, ‘coming home but still recovering’ and ‘finding a new balance’. The phenomenological descriptions reflect a recovery process that does not follow a linear build‐up, but comes with moments of success, setbacks, trying new steps and breakthrough moments of achieving mobilizing milestones.

Conclusion

Recovery from COVID‐19‐associated intensive care unit acquired weakness starts from a situation of alienation. Patients long for familiarity, for security and for recognition. Patients want to return to the familiar situation, back to the old, balanced, bodily self. It seems possible for patients to feel homelike again, not only by changing their outer circumstances but also by changing the understanding of themselves and finding a new balance in the altered situation.

Impact

Muscle weakness impacts many different aspects of ICU recovery in critically ill patients with COVID‐19‐associated intensive care unit acquired weakness. Their narratives can help nurses and other healthcare professionals, both inside and outside of the intensive care unit, to empathize with patient experiences. When healthcare professionals connect to the lifeworld of patients, they will start to act and communicate differently. These insights could lead to optimized care delivery and meeting patients' needs in this pandemic or a possible next.

Psychological Recovery after Critical Illness and Stay in Hospital ICU

Abstract The effects of critical illness and hospitalization in intensive care units (ICU) have been associated with the presence of negative psychological consequences. This study explores the experiences of sick people who were admitted to an ICU, seeking to know its repercussions on the self. In-depth qualitative interviews and participant observations were carried out with two people since their ICU admission until at least six months after discharge from the unit. Data was analyzed following an adaptation of the clinical qualitative method within a longitudinal frame and interpreted with Winnicott’s psychoanalytic perspective. This research managed to describe participants’ lived experiences and the ways they affected their psychic organization. To the interviewed, these experiences configured threshold situations which promoted a process of psychic disintegration. Psychological recovery, then, depends on the articulation of lived experiences, and is supported by facilitating intersubjective relationships that promote the expression of personal potentialities.

Patient Perceptions and Quality of Life in Pacemaker Recipients

Quality of life (QoL) reflects the multidimensional impact of a clinical condition and its treatment on patients’ daily lives. Although permanent cardiac pacemakers (PPMs) have made a significant contribution to the improvement of patients’ QoL, patients’ perceptions remain crucial after implantation. Hence, the present study was carried out to explore the QoL and the associated perceptions of PPM patients. A total of 150 PPM patients were enrolled. Data were collected using the Short Form–36 (SF-36) health survey, which also included patients’ characteristics. The statistical significance level was set at p < 0.05. The physical health score as measured by SF-36 was 42.9 ± 19.5 points, and the mental health score was 54.1 ± 26.6 points. Study participants had higher scores in emotional well-being (66.5 ± 18.8 points), and the lowest scores were in physical functioning (22.5 ± 10.7 points). The level of information about PPM was associated with physical role (p = 0.005), emotional role (p = 0.004), emotional well-being (p = 0.001), social functioning (p = 0.002), and general health (p = 0.001). Attendance at follow-up was associated with physical role (p = 0.015), emotional role (p = 0.014), social functioning (p = 0.003), and general health (p = 0.016). The belief that the device prevents disease deterioration was associated with physical role (p = 0.005), emotional role (p = 0.001), energy/fatigue (p = 0.010), emotional well-being (p = 0.004), social functioning (p = 0.001), pain (p = 0.005), and general health (p = 0.001). Dependency on the device was associated with energy/fatigue (p = 0.006), emotional well-being (p = 0.001), and social functioning (p = 0.002). Social difficulties due to the device were associated with emotional well-being (p = 0.001), social functioning (p = 0.001), pain (p = 0.001), and general health (p = 0.004). Family support was associated with emotional role (p = 0.023) and general health (p = 0.036), while pain was associated with information about the family (p = 0.001). In conclusion, the present findings regarding factors associated with QoL provide key opportunities for interventions aimed at facilitating positive adjustments after PPM implantation.

Patients' and relatives' experiences of post-ICU everyday life: A qualitative study

BACKGROUND

As advancements in intensive care treatment have resulted in decreased mortality rates, more attention has been given to the experience of life after critical illness. Despite an increase in literature describing the physical, psychological, and cognitive health problems arising after critical illness, there is a shortage of research exploring the lifeworld of patients and relatives, including its internal and external interplay in everyday life. Addressing this is essential for gaining insights into the experience of everyday life and recovery after critical illness.

AIMS AND OBJECTIVES

To explore patients' and relatives' experiences of everyday life after critical illness.

DESIGN

Data were collected using semi-structured interviews with 7 relatives and 12 patients. Interviews were audiotaped and transcribed verbatim.

METHODS

Drawing on the phenomenological-hermeneutic tradition, data were analysed using Ricoeur's theory of interpretation, as described by Dreyer and Pedersen.

FINDINGS

The lifeworld of everyday life was disclosed in the theme "Finding oneself after critical illness," described as an overall comprehensive understanding. This theme was divided into the subthemes (a) redefining the self, (b) reintegrating with family, and (c) resuming everyday life, which followed the trajectory of the three phases: the known past, the uncertain present, and the unknown future.

CONCLUSION

Critical illness and physical, psychological, and cognitive health problems create new and emerging difficulties in patients' and relatives' experiences of everyday life after intensive care. These experiences affect their understanding of themselves, their families, and their ability to resume pre-intensive care unit everyday life.

IMPLICATIONS FOR PRACTICE

The study underlines the need to supplement the affirmed domains in post-intensive care syndrome with a social domain to enhance family-centred care within the intensive care unit and across sectoral borders. Additionally, it highlights the need to develop rehabilitation strategies aimed at patients' and relatives' multifactorial health problems.

Stabilizing life: A grounded theory of surviving critical illness

OBJECTIVES

The experience of critical illness among patients is both complex and multifaceted. It can make patients vulnerable to long-term consequences such as impairment in cognition, mental health and physical functional ability which affects health related quality of life. This study aims to explore patients' patterns of behaviour during the process from becoming critical ill to recovery at home.

DESIGN

We used a classic grounded theory methodology to explore the main concern for intensive care patients. Thirteen participants were interviewed and seven different participants were observed.

SETTING

Three general intensive care units in Sweden, consisting of a university hospital, a county hospital and a district hospital.

FINDINGS

The theory Stabilizing life explains how patients' main concern, being out of control, can be resolved. This theory involves two processes, recapturing life and recoding life, and one underlying strategy, emotional balancing that is used during the whole process.

CONCLUSION

The process from becoming critically ill until recovery home is perceived as a constant fight in actions and mind to achieve control and stabilize life. This theory can form the basis for further qualitative and quantitative research about interventions that promotes wellbeing during the whole process.

'I want to get back!' A qualitative study of long-term critically ill patients' inner strength and willpower: Back home after long-term intensive care

AIMS AND OBJECTIVES

To provide insights into what promotes and challenges inner strength and willpower in formerly critically ill patients back home after a long-term ICU stay.

BACKGROUND

Critically ill patients demand great resources during an ICU stay, some experience great challenges after discharge from hospital. Knowledge about how health professionals can promote former long-term critically ill patients' inner strength and willpower after discharge is essential, but still missing.

DESIGN

A qualitative, hermeneutic-phenomenological approach using in-depth interviews with former long-term ICU patients.

METHODS

Seventeen long-term ICU patients were interviewed 6-20 months after ICU discharge. The consolidated criteria for reporting qualitative research was used (COREQ,2007).

RESULTS

Back home after hospital discharge, some former patients coped well while others suffered heavy burdens mentally and physically, along with economic problems. They handled their challenges differently: some found comfort and insight by reading their diary written by their ICU nurses, while several were struggling alone experiencing a lonesome silent suffering; these called for a follow-up support by the healthcare system.

CONCLUSION

Long-term ICU patients' inner strength and willpower are vital salutogenic resources supporting the fight back to one's former independent life. However, physical, mental and economic challenges drain their inner strength to go on and succeed. Several long-term ICU patients need health-promoting follow-up support after hospital discharge.

RELEVANCE TO CLINICAL PRACTICE

This study disclosed a lonely and silent suffering indicating a need for development of systematical health-promoting follow-up programmes including salutogenic components such as health-promoting conversations, diaries and web-based recovery programme along with a cell phone app.

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.

A qualitative study of long-term ICU patients' inner strength and willpower: Family and health professionals as a health-promoting resource

AIMS AND OBJECTIVES

To explore how the presence of family and health professionals influences long-term critically ill patients' inner strength and willpower as an incitement to keep fighting for recovery.

BACKGROUND

This study reports long-term critically ill patients' experiences of family and health professionals as health-promoting resources in terms of significance for their inner strength and willpower. Earlier research on this topic is scarce.

DESIGN

A qualitative, hermeneutic-phenomenological approach, within the context of Antonovsky's salutogenic theory.

METHODS

Seventeen long-term critically ill patients were interviewed once, at 6-18 months after ICU discharge. The consolidated criteria for reporting qualitative research (COREQ) were used (Supplementary File 1).

RESULTS

Four main themes identified how family and staff promoted and challenged the patient's inner strength and willpower: (a) the importance of family and friends; my family was surrounding me, (b) staff contributions, (c) challenges to inner strength and willpower in relation to family and (d) loneliness and indifferent care.

CONCLUSION

This study brings new knowledge from the long-term critically ill patient's view about the impact of family, friends and nurses on the patient's inner strength and willpower. All impact is experienced positively and negatively.

RELEVANCE TO CLINICAL PRACTICE

Knowledge from the long-term critically ill patient's view is vital in nurse-patient interactions to facilitate liberation of inner strength and willpower.

Greek nurses' perceptions on empathy and empathic care in the Intensive Care Unit

BACKGROUND

Empathy is a fundamental component of nursing practice impacting positively on the therapeutic process. Understanding the concepts of empathy and empathic care in the context of Intensive Care Units is essential for providing better care in high challenging environments. However, research on empathy in the ICU is scarce and mostly quantitative.

OBJECTIVES

To explore how ICU nurses perceive the concepts of empathy and empathic care.

DESIGN AND SETTING

A descriptive qualitative research design was applied using an inductive content analysis approach. Semi-structured interviews were conducted with nineteen ICU nurses in two hospitals in Greece.

FINDINGS

Data analysis revealed three main themes namely: "To become one of them", "Empathic Care" and "Integration of empathic care in practice". Findings corroborated the affective, cognitive and behavioral components of empathy. Nurses underlined that understaffing, increased workload and professional burnout impeded empathic care.

CONCLUSION

Empathy and empathic care in the ICU were perceived as closely related to patients' outcomes and quality care. Empathic care was arduous due to organisational issues. Despite that, ICU nurses appeared to promote empathic care in practice and sought ways to enhance it.

"Never in my mind to give up!" A qualitative study of long-term intensive care patients' inner strength and willpower-Promoting and challenging aspects

AIMS AND OBJECTIVES

To explore aspects that promote and challenge long-term ICU patients' inner strength and willpower.

BACKGROUND

Considerable research has been devoted to ICU patients' experiences; however, research on long-term ICU patients is limited. Studies in a health-promoting perspective focusing on long-term ICU patients' inner strength and willpower are scarce.

DESIGN

A qualitative, hermeneutic-phenomenological approach, using in-depth interviews.

METHODS

Seventeen long-term Norwegian ICU patients were interviewed once, at 6-18 months after ICU discharge. The consolidated criteria for reporting qualitative research was used (Data S1).

RESULTS

The lived experience of the phenomenon "inner strength and willpower" and what promotes and challenges this phenomenon in long-term ICU patients were represented by four main themes and nine subthemes. Promoting aspects comprised of two main themes and five subthemes: (a) "No doubt about coming back to life" with subthemes; "Strong connectedness to life; feeling alive and present," "Meaning and purpose; feeling valuable to somebody." (b) "How to ignite and maintain the spark of life," with the subthemes: "Practical solutions, coping skills from previous life experiences," "Provocative and inspiring experiences" and "Vivid dream experiences that ignite the willpower." Two main categories and four subcategories represented challenging aspects: (a) Exhaustion, weakness and discomfort; subthemes; "Physical challenges" and "Mental discomfort" and (b) "Tiring delusions," subthemes; "Living in the worst horror movie" and "Feeling trapped."

CONCLUSION

This study expands on previous studies by providing insights about what promotes and challenges long-term ICU patients' inner strength and willpower during their recovery trajectory.

RELEVANCE TO CLINICAL PRACTICE

Insights into the variety of long-term ICU patients' experiences during the recovery trajectory are important for ICU nurses to support and facilitate ICU patients' inner strength and willpower.

The lived experience of delirium in intensive care unit patients: A meta-ethnography

OBJECTIVES

The objectives were to interpretatively synthesise qualitative findings on patients' lived experience of delirium in the intensive care unit (ICU) and to identify meanings and potential existential issues that affect them during and after their experience. Patients may face existential challenges when they are vulnerable in their confusion, all while confronting the reality of their mortality in the critically ill state.

REVIEW METHODS

The study involved meta-ethnographic synthesis of published qualitative studies addressing the lived experience of delirium for patients in ICU based on a systematic literature search.

DATA SOURCES

MEDLINE, PsycINFO, Embase, Scopus, CINAHL, ProQuest, and Cochrane were the sources. Studies were selected based on the predefined inclusion/exclusion criteria. The identified studies were subjected to a quality appraisal based on a Critical Appraisal Skills Programme tool.

RESULTS

Based on the eligibility criteria, nine qualitative studies were included, of overall medium to high quality. One core theme, "a perturbing altered reality" and four main themes were identified: "disturbed sense of time", "omnipresent feeling of fear", "impact of human connection", and "perceiving surreal events". These four themes illustrate how the three salient existential issues of uncertainty, self-perceived helplessness, and death that are present in delirium make it a highly distressing experience for patients in ICU.

CONCLUSIONS

Critically ill patients who experience delirium appear to face intense existential issues, which may not be identified by care providers and may remain unaddressed during their ICU stay and after discharge. Patients report that addressing the memories of these issues would be therapeutic. Future research needs to explore care approaches to meet the unique psychosocial needs of critically ill patients with delirium.

From post-traumatic stress disorder to absolute dependence in an intensive care unit: reflections on a clinical account

This paper tells the story of one man's experience of terrifying hallucinations and nightmares in an intensive care unit (ICU), drawing attention to the reality that intensive care treatment induces emotional suffering severe enough to be identified as post-traumatic stress disorder (PTSD). A body of international research, confirmed by South African studies, links life-saving critical care to symptoms which qualify for secondary psychiatric diagnosis including of post-traumatic stress. Risk factors include pre-ICU comorbid psychopathology. Early on in the clinical encounter with the patient in this paper it emerged that he bore the scars of another trauma. He had been a soldier. Recounting the terror he experienced when he was being weaned off mechanical ventilation evoked memories of his military history. Paradoxically, these shifted the focus away from the symptoms of PTSD, to make the helplessness and dependency of ICU patients more visible. This patient's clinical account and patient experiences in other studies reveal the relational vulnerability of ICU patients. In as much as experiences of ICU treatment can be terrifying, the non-response of carers distresses patients. This interplay of wounding and care provides a starting point from which to explore how we account for the neglect of relational care that is a recurring theme in medical contexts, without blaming the carers. These questions find resonance in a South African novel to which the paper refers. A novel about war and trauma movingly portrays the internal conflict of the central character, a nurse and her quest not to care, as a defence against vulnerability. In these ways writing about the relational vulnerability of patients opened up questions about the social and institutional context of carer vulnerability.

Vulnerability in patients and nurses and the mutual vulnerability in the patient-nurse relationship

AIMS AND OBJECTIVES

To examine the mutual vulnerability of patients and nurses, anticipating that an enhanced understanding of the phenomenon may help reduce vulnerability.

BACKGROUND

Patient vulnerability is a key issue in nursing, aimed at protecting the patient from harm. In the literature, vulnerability is described both from a risk perspective and a subjective perspective. This implies that the objective dimension of patient vulnerability does not necessarily reflect the patient's own perception of being vulnerable. However, external judgment may influence internal perception. Adding to this complexity, attention has also been drawn to the vulnerability of the nurse.

DESIGN

A definition deduced from central literature on vulnerability captures the complexity of objective versus subjective vulnerability. Based on the perspective of vulnerability in general, vulnerability in healthcare services shows how dependency may increase patient vulnerability. Further, despite education, training and supportive settings, patients may increase nurse vulnerability. The core of this mutuality is explored in the light of Martin Heidegger's philosophy of being.

CONCLUSION

The patient's need for help from the nurse opens the patient to engage in supportive and/or harmful encounters. Thus, dependency adds to the vulnerability related to health issues. The nurse's vulnerability lies in her engagement in caring for the patient. If failing to provide proper care, the nurse's existence as 'a good nurse' is threatened. This is exacerbated if the patient turns against the nurse. Therefore, the core of vulnerability seems to lie in the fact that the patient and the nurse are both striving to be the persons they want to be, and the persons they have not yet become.

RELEVANCE TO CLINICAL PRACTICE

Recognition of the mutual vulnerability in the patient-nurse relationship calls for collective acknowledgement of the demanding nature of caring relationships, for support and for a strengthening of professional skills.

Dependency in Critically Ill Patients: A Meta-Synthesis

By necessity, critically ill patients admitted to intensive care units (ICUs) have a high level of dependency, which is linked to a variety of negative feelings, such as powerlessness. However, the term dependency is not well defined in the critically ill patients. The concept of “dependency” in critically ill patients was analyzed using a meta-synthesis approach. An inductive process described by Deborah Finfgeld-Connett was used to analyze the data. Overarching themes emerged that reflected critically ill patients’ experience and meaning of being in dependency were (a) antecedents: dependency in critically ill patients was a powerless and vulnerable state, triggered by a life-threatening crisis; (b) attributes: the characteristic of losing “self” was featured by dehumanization and disembodiment, which can be alleviated by a “self”-restoring process; and (c) outcomes: living with dependency and coping with dependency. The conceptual model explicated here may provide a framework for understanding dependency in critically ill patients.