Experience of patients in the intensive care unit. A qualitative study

How patients experience their stay in the Intensive Care Unit is often not discernible externally. The patients are frequently sedated and in such a life-threatening condition that they cannot express their experiences in this situation. Observation of the patients during their stay in ICU lends little to understanding their experiences. What one perceives from the outside can differ greatly from that which the patients experience themselves. Therefore, in this study, the patients were interviewed about their experiences several weeks to months after their release from the hospital. In this way, the patients could describe their perceptions from their own perspectives and thus be better understood. For this purpose the methodology of narrative interview was chosen so that the former patients could talk freely about what they experienced during their stay in ICU. Two of the interviews were completely analysed sequentially. The remaining interviews were used for purposes of comparison. The results of this study are the dimensions, which describe the experiences of patients in Intensive Care Units. The first dimension describes the experience of losses of memory, orientation impairment, and dreams. These experiences are closely related to outside influences, which could help to reconstruct the lost time and regain orientation, for example the reports of relatives. The second dimension represents how ill or healthy the patients considered themselves, and how much understanding they showed for their being treated in the ICU. The third dimension, which can be considered of overriding importance, outlines the patients' trust in relatives, the nursing staff and doctors.     

Relocating an intensive care unit: An exploratory qualitative study

BackgroundAs new hospitals are built to replace old and ageing facilities, intensive care units are being constructed with single patient rooms rather than open plan environments. While single rooms may limit hospital infections and promote patient privacy, their effect on patient safety and work processes in the intensive care unit requires greater understanding. Strategies to manage changes to a different physical environment are also unknown.ObjectivesThis study aimed to identify challenges and issues as perceived by staff related to relocating to a geographically and structurally new intensive care unit.MethodsThis exploratory ethnographic study, underpinned by Donabedian's structure, process and outcome framework, was conducted in an Australian tertiary hospital intensive care unit. A total of 55 participants including nurses, doctors, allied health professionals, and support staff participated in the study. We conducted 12 semi-structured focus group and eight individual interviews, and reviewed the hospital's documents specific to the relocation. After sorting the data deductively into structure, process and outcome domains, the data were then analysed inductively to identify themes.FindingsThree themes emerged: understanding of the relocation plan, preparing for the uncertainties and vulnerabilities of a new work environment, and acknowledging the need for change and engaging in the relocation process.Discussion and conclusionsA systematic change management strategy, dedicated change leadership and expertise, and an effective communication strategy are important factors to be considered in managing ICU relocation. Uncertainty and staff anxiety related to the relocation must be considered and supports put in place for a smooth transition. Work processes and model of care that are suited to the new single room environment should be developed, and patient safety issues in the single room setting should be considered and monitored. Future studies on managing multidisciplinary work processes during intensive care unit relocation will add to the learnings we report here.     

Family participation during physical activity in the intensive care unit: A longitudinal qualitative study

PurposeFamily-centered care has been implemented in the ICU to meet relatives' needs concerning information, support, participation and shared decision making. This study explores the needs, beliefs, feelings and behaviors of relatives of patients admitted to the ICU regarding participation during physical activity.MethodsLongitudinal qualitative study design following a grounded theory approach. Relatives were interviewed at 4, 8 and 12 days after the patient's ICU-admission. Data were analyzed using constant comparison.ResultsTwenty-five interviews were conducted in ten relatives. Relatives believed that physical activity in the ICU improves recovery. Participating in physical activity decreased their feelings of powerlessness and uselessness. Relatives mentioned that they would be stimulated to participate if they were invited, guided and informed by healthcare providers. The perceived reticence of healthcare providers, patient's health-changing capacity and the inability to communicate led to a more passive attitude towards participation.ConclusionsThe conceptual model shows how family participation during physical activity changes from a passive role, with negative beliefs and feelings of uselessness and powerlessness, to a more proactive participatory role. Relatives felt more useful and like they were part of the team. Providing relatives with additional information might be a viable strategy to help and stimulate participation.     

Communication and end-of-life care in the intensive care unit: patient, family, and clinician outcomes

Even though good communication among clinicians, patients, and family members is identified as the most important factor in end-of-life care in ICUs, it is the least accomplished. According to accumulated evidence, communication about end-of-life decisions in ICUs is difficult and flawed. Poor communication leaves clinicians and family members stressed and dissatisfied, as well as patients' wishes neglected. Conflict and anger both among clinicians and between clinicians and family members also result. Physicians and nurses lack communication skills, an essential element to achieve better outcomes at end of life. There is an emerging evidence base that proactive, multidisciplinary strategies such as formal and informal family meetings, daily team consensus procedures, palliative care team case finding, and ethics consultation improve communication about end-of-life decisions. Evidence suggests that improving end-of-life communication in ICUs can improve the quality of care by resulting in earlier transition to palliative care for patients who ultimately do not survive and by increasing family and clinician satisfaction. Both larger, randomized controlled trials and mixed methods designs are needed in future work. In addition, research to improve clinician communication skills and to assess the effects of organizational and unit context and culture on end-of-life outcomes is essential.     

Seasonal bed closures in an intensive care unit: a qualitative study

OBJECTIVE: To describe perceptions of the administrative procedures for seasonal bed closures and their consequences in the intensive care unit (ICU), and to critique this example of health care priority setting for legitimacy and fairness. DESIGN: A qualitative study using case study methods and interviews with key participants. We evaluated fairness and legitimacy of the bed closure process using 4 domains of the ethical framework of "accountability for reasonableness." SETTING: An university-affiliated medical/surgical ICU in Eastern Canada. PARTICIPANTS: ICU clinicians (9 bedside nurses and 5 physicians), and administrators (3 ICU managers and 2 senior hospital executives). MAIN OUTCOME MEASURES: Perceptions of ICU clinicians and administrators regarding the ICU bed closure decision-making process and its consequences. RESULTS: Emerging themes concerned: (1) bed closure rationale (including arbitrary decision making, bed closure masquerading as a code for a nursing shortage, and suboptimal evidence base for implementing closures); (2) bed closure process (viewed as unclear with insufficient prior publicity and inadequate subsequent review); and (3) adverse consequences (including safety issues, negative professional working relationships, and poor morale). Although an appeals mechanism existed, nurses were not available to staff reopened beds so this condition is only partially met. The relevance, publicity, and enforcement conditions for accountability of reasonableness were not satisfied, offering opportunities for improvement. CONCLUSION: Clinicians and administrators are readily able to identify shortcomings in the seasonal bed closure process in the ICU. These shortcomings should be targeted for improvement so that intensive care health services delivery is legitimate and fair.     

Cardiovascular nurses' experiences of working in the COVID-19 intensive care unit: A qualitative study

BackgroundCardiovascular nurses’ skills and experiences of cardiac critical care, management of cardiovascular emergencies, and mechanical circulatory support have been considered vital in providing nursing care for COVID-19 patients in intensive care units during the COVID-19 pandemic. To our knowledge, there are no studies have focused on the contribution and experiences of cardiovascular nurses in the critical care of COVID-19 patients.ObjectivesTo explore the experiences of cardiovascular nurses working in a COVID-19 intensive care unit during the pandemic.MethodsThe study was conducted as a qualitative study with phenomenological approach in June-December 2020. Study data were gathered from ten cardiovascular nurses through semi-structured interviews.ResultsSix themes emerged from the interview data: the duties and responsibilities in a COVID-19 intensive care unit; the differences of COVID-19 intensive care unit practices from cardiovascular practices; the transferrable skills of cardiovascular nurses in a COVID-19 intensive care unit; the difficulties encountered working in a COVID-19 intensive care unit; the difficulty of working with personal protective equipment; and the psychosocial effects of working in a COVID-19 intensive care unit.ConclusionCardiovascular nurses made an important contribution to the management of nursing services with their experiences and skills in the COVID-19 pandemic.     

Staff perception of the implementation,enablers and barriers to pediatric intensive care unit diary writing: A qualitative study

ObjectivesTo explore how the multi-professional pediatric intensive care unit staff experienced the implementation of the diary.Research Methodology/DesignQualitative study using the implementation research approach.Setting: a six-bed pediatric intensive care unit at a large Italian tertiary care pediatric hospital, treating patients with acute conditions from the Emergency Department or hospital wards.Main outcome measuresHealthcare providers’ experiences of the implementation of the diaries. Data was collected by focus groups and interviews and thematic analysis was performed.FindingsThree focus groups and four interviews with staff were conducted after the implementation of thediaries from August 2020 to June 2021. Staff describe an initial disbelief towards the effectiveness of diaries followed by an increasing perception of their relevance for parents’ emotional expression through shared narration. Diaries are reported as a beneficial communication tool between the family, the child, and health care providers, increasing staff understanding of parents’ experiences of their child’s admission and parents’ sense of the care received by their child. For staff, barriers for diary writing were logistics, lack of time, limited sense of ownership, fear of legal retaliation and fear of emotional labor.ConclusionHealth care providers perceived diaries as beneficial for parents and the healthcare team, potentially supporting their partnership as recommended by Family Centered Care models. The enablers and barriers that emerged for diary writing can support the development of implementation strategies to prevent the reported challenges to diary writing in the healthcare team, enhancing their uptake in the pediatric intensive care unit setting.     

Intensive care unit capacity strain and adherence to prophylaxis guidelines

PurposeThe purpose of the study is to examine the relationship between different measures of capacity strain and adherence to prophylaxis guidelines in the intensive care unit (ICU).Materials and methodsWe conducted a retrospective cohort study within the Project IMPACT database. We used multivariable logistic regression to examine relationships between ICU capacity strain and appropriate usage of venous thromboembolism prophylaxis (VTEP) and stress ulcer prophylaxis (SUP).ResultsOf 776 905 patient-days eligible for VTEP, appropriate therapy was provided on 68%. Strain as measured by proportion of new admissions (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.90-0.91) and census (OR, 0.97; 95% CI, 0.97-0.98) was associated with decreased odds of receiving VTEP. With increasing strain as measured by new admissions, the degradation of VTEP utilization was more severe in ICUs with closed (OR, 0.85; 95% CI, 0.83-0.88) than open (OR, 0.91; 95% CI, 0.91-0.92) staffing models (interaction P < .001). Of 185 425 patient-days eligible for SUP, 48% received appropriate therapy. Administration of SUP was not significantly influenced by any measure of strain.ConclusionsRising capacity strain in the ICU reduces the odds that patients will receive appropriate VTEP but not SUP. The variability among different types of ICUs in the extent to which strain degraded VTEP use suggests opportunities for systems improvement.     

Improving student supervision in a Norwegian intensive care unit: a qualitative study

The purpose of the study was to investigate intensive and critical care nurses' experiences of an empowerment program in the context of their role as student supervisors. Multistage focus group interviews were carried out and qualitative content analysis was performed in several steps. The overall results highlighted the need for strategies aimed at ensuring quality. The emerging themes were time, leadership and shared responsibility. Enough time promoted motivation, learning and reflection. Obligations to the student limited their leisure time and family life, and imposed some limitations during working hours. Leadership was perceived as crucial and leaders should act as strategic managers of development. The balance between "shared responsibility" and one supervisor in charge of one student was highlighted. There is a need to strengthen and improve the system of student supervision. There is a need to allocate time for learning and reflection. Who is responsible for the students must be clearly defined in the hospital, the university and in the intensive care unit, and it must be communicated.