Recalling ICU Experiences: Patients Perspectives

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1 Middle-East Journal of Scientific Research 19 (Innovation Challenges in Multidiciplinary Research & Practice): , 2014 ISSN IDOSI Publications, 2014 DOI: /idosi.mejsr icmrp.16 Recalling ICU Experiences: Patients Perspectives Kim Lam Soh, Kim Geok Soh, Noor Airini Ibrahim, Nor Zehan Ahmad, Salimah Japar and Rosna Abdul Raman 1 Nursing Unit, Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, 43400, Selangor Darul Ehsan, Malaysia 2 Department of Sport Studies, Faculty of Educational Studies, Universiti Putra Malaysia, Serdang, 43400, Selangor Darul Ehsan, Malaysia 3 Anesthesiology Unit, Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, 43400, Selangor Darul Ehsan, Malaysia. 4 Department of Nursing Science, Faculty of Medicine,University of Malaya, Kuala Lumpur, Malaysia Abstract: Patients in ICU are commonly in a critical condition and they need several types of support such as mechanical ventilation to sustain their life. However, the supports provided can also create an unpleasant experience even after they have been discharged from ICU. This study aims to determine the types of unpleasant experiences suffered by post ICU patients during their ICU stay. Approximately 65.4% of the post ICU patients were able to recall the physical and psychological effects of their ICU experience, with the five most stressful experiences being endotratracheal suctioning, pain, confinement to bed, general discomfort, ventilator dependence and needle punctures. This study provides a set of baseline information to the health care providers especially nurses to improve patient care in the ICU. Key words: Patient s experience Intensive care unit Malaysia INTRODUCTION An intensive care unit (ICU) is a specialized section of a hospital which provides comprehensive and continuous care for persons who are critically ill and who can benefit from the treatment [1]. Patients will remain in their critical condition for various lengths of time and will need several types of life support, such as respiratory, cardiovascular or renal. These life support given can be considered as a stressful life event, or even a life-threatening condition [2, 3]. Being in ICU itself might be a stressful life event due to: invasive instrumentation, inability to breathe normally, inability to communicate with family or staff and frequently disturbed sleep [4, 5]. This study will provide feedback to nurses about their patients experiences in ICU. This includes identifying problem which may be alleviated through changes in practice [6]. Greater knowledge of patients experiences can help nursing professionals gain a deeper understanding of their health processes and provide a more solid basis for nursing care, or even pave way for introduction of new measures to prevent the unpleasant experiences felt by the patients. Thus, increased awareness regarding patients psychological or physical experiences will assist nurses and other health care professionals in both prevention and early intervention to provide a holistic care for critically ill patients. Literature Review: Patients in ICU have varied memories of their ICU experiences. Some people have extensive memories, but others recall little of their ICU stay. Many of these memories include being cared for by nurses. ICU environmental, medication or critical illness are among the important factors in the formation of factual and imaginary memories in ICU patients [7]. Claesson, Mattson and Corresponding Author: Soh Kim Geok, Faculty of Educational Studies, Universiti Putra Malaysia, UPM, Serdang, Selangor, Malaysia. Tel:

2 Idvall [1] found that patients recalled both real described as friendly or relaxed by 94% of the patients [6]. experiences and imaginary experiences, such as Other study found that the most frequently reported fragmentarily remembered being ventilated, visiting unpleasant experiences were arterial blood gas sampling relatives, the environment and the staff and some patients with 48% (n=80) of the patients, followed by tracheal expressed different imaginary experiences such as suctioning with 30% of 68 ventilated patients [18]. pleasant dreams, nightmares and strange dreams [5, 8, 9]. A similar result was also found by Granja et al., [17] who Stein-Parbury and McKinley [10] reviewed 26 studies on discovered that the most stressful experiences reported memories of ICU patients and they found that % were tracheal tube aspiration (81%), nasogastric tube of the patients could remember parts or all of their stay in (75%) and pain (64%). the ICU. In another study on discomfort and factual The environments in the hospitals, specifically the recollection of 125 patients discharged from the ICU, ICUs, lead to patients experiencing a range of adverse van de Leur et al. [2] found that a recollection of any psychological reactions, which many continue to cause type of discomfort was reported by 54% of patients. distress to patients for many months even after their They suggest that the presence of endotracheal tube discharge from the hospital [1, 11]. According to (ETT), medical interventions and noise were among Eddleston, White and Guthrie [12] survivors of critical the sources of discomfort most frequently reported. illness have reported to experience physical and Discomfort was also found to occur in patients who had psychological disability after their stay in ICU. experienced dreams and nightmares [17, 19]. Similarly, Broom head and Brett [13] also found that patients were unable to accomplish even simple physical MATERIALS AND METHODS tasks without exhaustion after a period of critical illness. A variety of aspects related to physical status may have Design: A cross-sectional study design using a survey contributed to impair physical functioning and these method was used to determine patients experiences may have important impacts on the quality of life. [14] during their stay in the ICUs of four government hospitals These physical problems include difficulties with eating, in Malaysia from November 2007 until January mobility, fatigue, weakness and voice and taste changes. Approval to conduct this study was granted by at the Psychological experiences were also reported by Ministry of Health Malaysia. 47% (n=80) of patients who had unpleasant dreams and nightmares and the experiences are related to death, Participants and Data Collection Process: All adult travelling, fear and misplaced identity [15]. Factors which patients, aged 18 and above, ventilated, stayed for more have been considered as affecting the psychological state than 24 hours, with no gross neurological deficit and no of critically ill patients are drugs, environment, disease history of psychotic episodes, were invited to participate process, psychosocial and pain, which lead to confusion in the study (n=104). The patients data were retrieved states or depression [4, 7, 16]. Findings from these studies from admission book in the ICUs and patients were then indicated that frightening memories, hallucinations and followed up in the ward at least three days after being nightmares are among potential threats to patients later discharged from ICU. They were informed about the psychological recovery. These findings are supported by study and a written consent was obtained. The researcher Granja et al., [17] who also found that patients reported interviewed each individual patient by a structured to have dreams and nightmares during their ICU stay and questionnaire. The researchers are bilingual with more were still being disturbed by them even at six months after than 10 years of critical care experience. ICU discharge. In addition, these patients also reported current disturbance to their daily life because of those Instrument: A questionnaire adapted from Granja et al. dreams and nightmares may suggests that patients are [17] was used. The questionnaire consists of three suffering from post-traumatic stress disorder-related sections, comprising of 25 questions. Section one focused symptoms or PTSS [9]. on the patients demographic and ICU admission profile. The ICU environment, medical and nursing Section two (14 items) assessed the memories retained by interventions are believed to have contributed to the the patients on the ICU environment, their relationship experiences felt by the patients. However, a study which with health care professionals, dreams, nightmares, sleep evaluated 100 patients who were experiencing ICU disturbances, difficulties in concentrating recent events, admission suggested that the ICU atmosphere had been fatigue as well as being able to return to the previous level 107

3 of activity. Direct question on memories were asked by their stay in ICU to reveal any physical and psychological selecting the best choice (5 items) and also yes and no effect. Consequently, categorical variables were described answer (9 items). Section three consists of 22 items as frequencies, percentage were used for continuous which were designed to gather information on the variables. patients experiences towards procedures and events during their ICU stay such as ETT suctioning, pain, noise, RESULTS ventilator dependence and sleep. These items were classified in one of five categories: 0 ( I don t remember ), A total of 104 post ICU patients were included 1 ( It was not hard ), 2 ( It was indifferent ), 3 ( It was in this study. Of the 104 participants included in the hard, but it had to be ), 4 ( It was very hard ) and 5 study, 59(57%) were male, 45 female and the median ( It was awful ). age was 43 years old. The majority of the participants The questionnaire was sent to four experts, were Malays 71.2% (n=74), followed by Chinese, comprising of two anaesthesiologists consultants from Indian and others. The length of stay of the a government hospital and a private institute, one participants ranged from 1 to 18 days. Majority of the intensivist and one critical care nurse from another participants had stayed in the ICU for 1 to 3 days. government hospital. All experts consulted agreed on More than half (57%) of the participants admitted to the relevancy and clarity of the questionnaires. They also ICU was categorised as emergency and 43% was agreed that the sampling of the questions had been elective. adequate and it thus reflected the recollection of the Participants were asked about their ability to recall patients experiences. The questionnaire was then their ICU experiences. A total of 68(62.5%) of the improved based on the experts comments. A combination participants remembered their hospital admission and of Bahasa Malaysia and English language were used and 47(45.2%) participants remembered about their ICU reviewed by a lecturer from the Faculty of Modern admission. However, 36(35%) participants stated that Language and Communication Universiti Putra Malaysia. they did not remember anything about the whole ICU The questionnaire was pre-tested in one of the stay. Therefore, for the analysis of the experience felt government hospital. Patients with all the listed criteria by the patients the data from the 68 participants were were given the structured questionnaires after being used. Table 1 shows the patients reported experiences in consented. In total, three patients were involved in the the ICU. pre-test; nevertheless, no further alteration was done The various stressful experiences recalled by after the pre-test. the patients are displayed in Table 3. Endotracheal suctioning was reported as the most stressful Data Analysis: All data were processed using Statistical procedure. Being confined to bed (62%) was the top Package for Social Sciences (SPSS). Descriptive statistics as the most stressful ICU environments. The most were used to analyze the patients experiences towards stressful experience effecting ICU patients Table 1: Demographic characteristics of ICU patients Characteristics ICU A (n=41) n (%) ICU B (n=23) n (%) ICU C (n=21) n (%) ICU D (n=19) n (%) Total (n=104) n (%) Gender 23 (56.1) 12 (52.2) 15 (71.4) 11 (57.9) 59 (56.7) Male 18 (43.9) 11 (47.8) 6 (28.6) 8 (42.1) 45 (43.3) Female Median age, years (18-71) 46 (20-71) 42 (19-67) 45 (18-67) 38 (20-60) 43.5 (18-71) Ethnic Malay 27 (65.9) 19 (82.6) 15 (71.4) 13 (68.4) 74 (71.2) Chinese 6 (14.6) 2 (8.7) 3 (14.3) 4 (21.1) 15 (14.4) Indian 7 (17.1) 1 (4.3) - 2 (10.5) 10 (9.6) Others 1 (2.4) 1 (4.3) 3 (14.3) - 5 (4.8) Admission category, n (%) Elective 14 (34.1) 12 (52.2) 13 (61.9) 8 (42.1) 45 (43.3) Emergency 27 (65.9) 11 (47.8) 8 (38.1) 11 (57.9) 59 (56.7) Median days in ICU (1-18) 2.8 (1-10) 3 (1-18) 2 (1-9) 2 (1-10) 3(1-18) Sedation Yes 31 (75.6) 18 (78.3) 16 (76.2) 16 (84.2) 80 (76.9) No/NA 10 (24.4) 5 (21.7) 5 (23.8) 3 (15.8) 24 (23.1) 108

4 Table 2: The ability of the patients to recall ICU experiences ICU experiences n Yes n(%) No n(%) Ability to see and felt during your ICU stay? (65.4) 36(34.6) Do you remember your admission on hospital? (62.5) 39(37.5) Currently, do you feel more fatigue than previously to ICU stay? (46.2) 56(53.8) Do you remember your admission on ICU? (45.2) 57(54.8) Currently, do you have sleep disturbances? (40.4) 62(59.6) Have you had any dreams during your stay in the ICU? 68 19(27.9) 49(72.1) Have you had any nightmares during ICU stay? 68 8(11.8) 60(88.2) Table 3: Recollection of stressful experiences among ICU patients ICU experiences (n=68) With stress, No of participants (%) Without stress, No participants (%) Endotracheal suctioning 51(75.0) 17(25.0) Pain 46(67.6) 22(32.4) Confinement to bed 42(61.8) 26(38.2) General discomfort 41(60.3) 27(39.7) Ventilator dependent 40(58.8) 18(26.5) Needle puncture 33(48.5) 35(51.5) psychologically was pain (68%), followed by general More than 40% (n=104) of the patients reported of discomfort (60%). Other ICU experiences were portrayed still having sleep disturbances after their ICU discharge. in Table 3. Granja et al. [17] found that patients reported of still being disturbed by dreams and nightmares six months DISCUSSION after being discharged from ICU. These disturbances by dreams and nightmares may have effects on the patient s This study found that out of 104 participants daily activities [17, 21, 23]. Therefore, it is important to approached, 68 (65%) of the ICU patients were able to promote better sleep for ICU patients during their ICU recall their experience in the ICU. These experiences might stay. This includes creating conducive environments affect the patient even after they are discharged from the and orientated patients. Besides that, nurses need to ICU [20, 21] and delay their recovery period. A total of avoid unnecessary nursing interventions carried out 68 patients had some memory of their ICU stay. However, throughout the night which might lead to interrupted 36(35%) of patients stated that they cannot remember and poor quality of sleep. their ICU stay. This finding was similar with the ones About 46% of 104 patients described feeling of gauged in the previous studies, whereby approximately fatigue than previously to ICU stay. Some patients even 21 to 30% of their patients could not remember indicated that they were unable to accomplish even simple experiences in ICU [9, 17, 22]. Several factors may have physical tasks without exhaustion after being discharged affected the patients memory of the ICU, including the from ICU. A variety of physical status may contribute to severity of illnesses and medications [9, 10, 22]. impair physical functioning. Studies had discovered that The result of this study also revealed that dreams or common physical problems after three to six month nightmares were less common, but were still present for period of ICU stay include weakness, weight loss, some patients; about 19 (28%) of patients reported of poor appetite and painful joint [2, 7, 20]. Whereas, having had dreams and 12% (n=68) from them reported Granja et al. [17] found 199 (57%) of their participants nightmares during their ICU stay. These include the reported more fatigue for six month than before the ICU dreams such as about the ICU environments, their work stay and their ability to return to the previous level of environments and the post-operative patients usually activity also decreased in some patients. These problems had dreams about the tissues from their bodies such as can continue even for six to twelve months after patients tumour, which had been removed during the operations. discharged from ICU [19, 24, 25]. Therefore nurses and More recent studies reported the incidences of dreams health care team must have greater awareness of the and nightmares which marked up to 47% of the patients, potential for problems after patients discharge from ICU with themes such as travelling, feared of and misplaced and discharged planning must be considered as a identity as being prevalent [7, 15]. responsibility for the ICU staff. 109

5 Endotracheal tube suctioning, pain, confinement to patients after ICU discharge could influence both care in bed, general discomfort and being ventilator dependent the ICU for future patients and care in the wards after were among the ICU experiences described as being more discharge from ICU. To improve the quality of intensive stressful experiences to the participants. Up to 75% (n=68) care, it is essential to make the nursing and medical teams of the participants reported that ETT suctioning as the members aware of these findings. Thus, ICU nurses must most stressful experiences. Other studies also found that provide effective care while at the same time effectively ETT suctioning as the most stressful procedures by communicate to alleviate fear and stress of the patients more than 50% of the participants [2, 9, 17, 22]. Majority during their ICU stay. of the participants reported pain and general discomfort; 68% and 60%, respectively. In this study feeling of REFERENCES discomfort may be due to pain from ETT suctioning, medical interventions or prolong immobilization. 1. Claesson, A., H. Mattson and E. Idvall, The study by van de Leur et al. [2] found that the reasons Experiences expressed by artificially for discomfort were related to the presence of ETT or ventilated patients. Journal of Clinical Nursing, ETT suctioning. Similarly, a study surveying ICU 14(1): stressors among patients after discharged from ICU, 2. van de Leur, J.P., et al., Discomfort and factual discovered that 44% (n=100) reported ETT suctioning as recollection in intensive care unit patients. Critical the most stressful experiences, thus the pain induced by Care, 8(6): R467. ETT suctioning had become a source of discomfort to 3. Todres, L., P. Fulbrook and J. Albarran, the patients [26]. Therefore, nurses must be more On the receiving end: A hermeneuticresponsive to patients feeling because the ETT phenomenological analysis of a patient's struggle suctioning can be distressing for patients. Stress to cope while going through intensive care., associated with the ETT suctioning could be reduced by 5(6): assessment prior to the suctioning, but this was not 4. Meriläinen, M., H. Kyngäs and T. Ala-Kokko, done due heavy routine works. At the same times, nurses 24-hour intensive care: an observational study of an must also assess patients comfort levels and reactions to environment and events. Intensive and Critical Care the ETT. In addition, adjuvant therapies such as the use Nursing, 26(5): of analgesics to reduce ETT pain, or the use of sedatives 5. Haghbin, S., et al., Visiting Hour Policies in to improve sleep could be helpful in ensuring patients Intensive Care Units, Southern Iran. Iranian Red comfort [22]. The Ventilator Care Bundle (VCB) which was Crescent Medical Journal, 14(3): introduced recently has one component that were to 6. Holland, C., C.L. Cason and L.R. Prater, implement daily "sedation vacations" and assessment of Patients recollections of critical care. Dimensions of early readiness to extubate. Therefore, this may help to critical care nursing, 16(3): reduce the pain cause by ETT suctioning. 7. Cutler, L.R., M. Hayter and T. Ryan, A critical There are 42(62%) of the participants who reported review and synthesis of qualitative research on confinement to bed during ICU stay as a stressful patient experiences of critical illness. Intensive and experiences. Thus, early ambulatory such as sitting on the Critical Care Nursing, 29(3): chair with the supervision from nurses or other health care 8. Roberts, B.L., et al., Patients dreams in ICU: team members will facilitate patients mobility and avoid Recall at two years post discharge and comparison to any complications from being immobilization in the bed. delirium status during ICU admission: A multicentre cohort study. Intensive and Critical Care Nursing, CONCLUSION 22(5): Samuelson, K.A., Unpleasant and pleasant The results of this study showed that patients memories of intensive care in adult mechanically experienced both physical and psychological effects after ventilated patients - Findings from 250 interviews. their ICU stay. Nearly two third of the participants Intensive and Critical Care Nursing, 27(2): underwent and remembered painful procedures, 10. Stein-Parbury, J. and S. McKinley, Patients' primarily ETT suctioning and though one third of them experiences of being in an intensive care unit: a were not able to recall ICU events during their ICU stay. select literature review. American Journal of Critical The physical and psychological problems experienced by Care, 9(1):

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