"Hope at a crossroads" - Experiences of hope in intensive care patients: A qualitative study.

BACKGROUND: Hope is closely connected to experiences of health and illness. In critical illness, the future may be uncertain regarding survival, recovery, and daily functioning. More knowledge is needed on how to support hope in patients in intensive care units and during the following rehabilitation period. OBJECTIVES: The aim of this study was to explore hope and its impacting factors among critically ill patients in the intensive care unit. METHODS: This was an exploratory study using semistructured interviews for data collection. Thirteen patients discharged from intensive care were interviewed while still in hospital. Data were analysed using thematic analysis. The consolidated criteria for reporting qualitative research were used for reporting this study. FINDINGS: Three themes, consisting of 8 subthemes, were generated through the analysis. The first theme presented, 'Hope at the point of uncertainty', describes the perception of hope as a phenomenon in critical illness, while the last two, 'Nourishment for hope' and 'Barriers to hope', comprise possible promoting and constraining factors affecting hope during intensive care The overarching theme 'Hope at a crossroads' reflects the overall patient experience of hope in critical illness. CONCLUSION: To maintain or regain hope, healthcare personnel working with critically ill patients should be aware of the importance of encouraging and acknowledging physical progress even when small. Furthermore, they should attend to patients' relational needs and facilitate their ability to interact as the persons they are, not only as patients.

Use of Facebook in a quality improvement campaign to increase adherence to guidelines in intensive care: A qualitative study of nurses' and physicians' experiences.

OBJECTIVES: This study aimed to explore intensive care unit nurses' and physicians' experiences with professional content provided through closed Facebook groups, as part of a quality improvement campaign to improve guideline adherence. RESEARCH METHODOLOGY: This study used an exploratory qualitative design. In June 2018, data were collected through focus groups of intensive care nurses and physicians who also were members of closed Facebook groups. Data were analysed using reflexive thematic analysis, and the study was reported according to the consolidated criteria for reporting qualitative research. SETTING: The study's setting was four intensive care units at Oslo University Hospital, Norway. Professional content on Facebook comprised audit and feedback on quality indicators on intensive care topics with related pictures, videos, and weblinks. FINDINGS: Two focus groups of 12 participants were included in this study. Two main themes were identified: 'One size does not fit all ' described that quality improvement and implementation are influenced by several factors related to current recommendations and personal preferences. Various strategies are required to serve different purposes and meet individual needs. 'Matter out of place' described conflicting experiences of being offered or exposed to professional content on Facebook. CONCLUSION: Although the audit and feedback on quality indicators presented on Facebook motivated improvements, professional content on Facebook was perceived as inappropriate. Hospital platforms with applicable features of social media, such as reach, availability, convenience, ease, and possibility for commenting, were suggested to secure professional communication about recommended practices in intensive care units. IMPLICATIONS FOR CLINICAL PRACTICE: Social media platforms may be useful for professional communication among ICU personnel, but appropriate hospital applications with available and applicable social media features are recommended and needed. The use of several platforms may still be needed to reach all.

Coping in times of disruption and deprivation-Experiences of family members during COVID-19 patients' critical illness: A qualitative study.

AIM: To explore the experiences and needs of family members during the course of COVID-19 critical illness from onset to rehabilitation. DESIGN: An exploratory qualitative study. METHODS: Twelve family members of surviving critically ill COVID-19 patients and restricted from visiting the patients, were interviewed digitally. Reflexive thematic analysis was used. RESULTS: Three themes were generated from the data; 'Experiencing a double burden', 'Becoming an insignificant other' and 'Regaining significance'. Family members were often ill themselves, which represented an extra burden when the patient deteriorated. From admission, the family members became bystanders, deprived of most contact with the patients, as communication and information from the intensive care unit appeared unstructured and haphazard. However, when patients were discharged, great responsibility was placed on the family members.

Finding the right words: A focus group investigation of nurses' experiences of writing diaries for intensive care patients with a poor prognosis.

BACKGROUND: The overall purpose of diaries written during an intensive care stay is to help patients fill in memory gaps from the illness trajectory, which might promote long-term psychological recovery. Diaries have also been shown to benefit nurses in maintaining a view of the patient as a person in the highly technical environment and to promote reflection. There is a lack of research on how nurses might be affected by writing a diary for critically ill patients with a poor prognosis. OBJECTIVES: The aim of this study was to investigate nurses' experience of writing diaries for intensive care patients with a poor prognosis. METHODS: This study has a qualitative descriptive design and was inspired by the methodology of interpretive description. Twenty-three nurses from three Norwegian hospitals with a well-established practice of writing diaries participated in four focus groups. Reflexive thematic analysis was used. The study was reported according to the Consolidated Criteria for Reporting Qualitative Research checklist. FINDINGS: The overarching theme resulting from our analysis was "Finding the right words". This theme represents the challenge of writing in view of the uncertainty of the patient's survival and of who would read the diary. It was important to strike the right tone with these uncertainties in mind. When the patient's life could not be saved, the purpose of the diary expanded to comforting the family. To put an extra effort into making the diary something special when the patient was dying was also a meaningful activity for the nurses. CONCLUSIONS: Diaries may serve other purposes than helping patients to understand their critical illness trajectory. In cases of a poor prognosis, nurses adapted their writing to comfort the family rather than informing the patient. Diary writing was meaningful for the nurses in managing care of the dying patient.

Above cuff vocalisation (ACV): A scoping review.

INTRODUCTION: Patients in intensive care frequently suffer from not being able to communicate verbally. The aim of this scoping review was to study the safety and effectiveness of the above cuff vocalisation (ACV) on speech and quality of life (QOL) in patients dependent on a cuffed tracheostomy. METHODS: A scoping review was conducted. The databases Ovid Medline, Cochrane Library, and Embase were systematically searched in May 2020. We included clinical studies with patients exposed to ACV where speech, QOL or safety issues were assessed. RESULTS: Overall, 17 studies were included, of which 15 were observational and 2 were randomised controlled trials. Totally, 231 patients were included. ACV enabled most of the included patients (115/131; 88%) to speak with an audible voice or whisper (moderate quality of evidence). Voice related QOL (V-RQOL) and QOL in mechanically ventilated patients (QOL-MV) improved from pre- to post- ACV compared to a control group not tolerating a one-way speaking valve (P = .01 and P = .04, respectively) (very low quality of evidence). Several minor complications or problems were reported in 20/75 (27%) cases in addition to two serious adverse events: subcutaneous emphysema in one patient where the tracheostomy was dislodged and a distended trachea in another due to the misconnection of continuous gas to the cuff (low/ very low quality of evidence). CONCLUSION: ACV facilitated communication in patients dependent on a cuffed tracheostomy and attempting to communicate. Quality of evidence in improved V-RQOL and QOL-MV was very low. Several minor complications and two serious adverse events were reported.

"Please mind the gap": A secondary analysis of discomfort and comfort in intensive care.

AIMS AND OBJECTIVES: To explore in depth discomfort in intensive care as experienced by patients and attended to by critical care nurses. BACKGROUND: Discomfort in illness is complex and persistent, and its alleviation is a challenge for nurses working in intensive care units (ICU). In previous studies, we showed that ICU patients described little actual pain but suffer from much discomfort. Critical care nurses had a systematic approach to the treatment of pain, but were more haphazard in dealing with other types of discomfort. DESIGN: Secondary qualitative analysis of data from two previous exploratory studies. METHODS: Content analysis was used on existing data from 28 interviews with ICU patients, and 16 field notes and interviews with critical care nurses. Kolcaba's Comfort Theory was applied for further analysis. The COREQ checklist was used. RESULTS: Three themes, "Being deprived of a functioning body", "Being deprived of a functioning mind" and "Being deprived of integrity" characterised the discomfort experienced by ICU patients. The nurses appeared to attend to all areas of discomfort expressed by patients. In need of, and providing acknowledgment and alleviation became a common overarching theme. We identified a comfort gap caused by the discrepancy between the patients' needs and the nurses' achievements in fulfilling these needs. CONCLUSIONS: A gap exists between ICU patients' comfort needs and nurses' achievements in fulfilling these, indicating that discomfort currently is an inevitable part of the critical illness trajectory. Increased knowledge about how the brain is affected in ICU patients and more systematic approaches to assessing comfort needs and enhancing comfort may support nurses in fulfilling patient needs and possibly diminish the existing comfort gap. RELEVANCE FOR CLINICAL PRACTICE: An increased understanding of the complex experience of discomfort in ICU patients may bring about more systematic approaches to enhance comfort and direct for education and further research.

"Having the compass-drawing the map": Exploring nurses' management of pain and other discomforts during use of analgosedation in intensive care.

AIM: To explore the deliberation and enactment processes of nurses in relation to pain and other discomforts in the critically ill patients after the implementation of an analgosedation protocol. BACKGROUND: Nurses in intensive care units (ICU) face great challenges when managing pain and other discomforts and distinguishing between patients' needs for analgesics and sedatives. An analgosedation protocol favouring pain management, light sedation and early mobilization was implemented in a university hospital ICU in Norway in 2014. Changing sedation paradigms resulting in an increasing number of awake patients during critical illness is expected to affect nursing practice. DESIGN: Exploratory, single-unit study in a mixed adult ICU. METHODS: Data collection with participant observation and semi-structured interviews in sixteen clinical situations in 2014 and 2015. Thirteen experienced certified critical care nurses were included. Thematic content analysis was conducted. RESULTS: An overall theme "Having the compass-drawing the map" emerged from the analysis. The protocol or strategy of analgosedation appeared to provide a direction for treatment and care, although requiring extensive interpretation of needs and individualization of care, often in challenging situations. The overall theme was abstracted from three themes: "Interpreting a complex whole," "Balancing conflicting goals" and "Experiencing strain from acting across ideals." CONCLUSION: Nurses seem to attend adequately to patient pain, but the approach to discomforts other than pain appears unsystematic and haphazard. More explicit goals of care and strategies to handle discomfort as distinct from pain are needed. More research is needed to identify effective comfort measures for ICU patients.

"Pain relieved, but still struggling"-Critically ill patients experiences of pain and other discomforts during analgosedation.

AIMS AND OBJECTIVES: To explore how critically ill patients treated according to a strategy of analgosedation experience and handle pain, other discomforts and wakefulness. BACKGROUND: Patients experience both pain and discomfort while in the intensive care unit. International guidelines recommend focused pain treatment and light sedation. An analgosedation protocol favouring pain management, light sedation and early mobilisation was implemented in our university hospital medical and surgical intensive care unit in Norway in 2014. The analgosedation approach may affect patients' experiences of the intensive care unit stay. DESIGN: Exploratory, descriptive design using semi-structured interviews. METHOD: Eighteen adult patients treated in intensive care unit >24 hr and receiving mechanical ventilation were interviewed 1-9 days after intensive care unit discharge. Ten patients were re-interviewed after 3 months. Data were analysed using the "systematic text condensation" approach. FINDINGS: Four main categories emerged from the analysis: "In discomfort, but rarely in pain," "Struggling to get a grip on reality," "Holding on" and "Handling emotionally trapped experiences." "Pain relieved, but still struggling" was the overarching theme. Analgosedation provided good pain relief, but patients still described frequent physical and psychological discomforts, in particular related to mechanical ventilation, not understanding what was going on, and experiences of delusions. To come to terms with their intensive care unit stay, patients needed to participate, trust in others and endure suffering. After hospital discharge, patients described both repression of experiences and searching for recognition of what they had gone through. RELEVANCE TO CLINICAL PRACTICE: Despite good pain relief during analgosedation, other discomforts were commonly described. Critically ill patients still experience an intensive care unit stay as a traumatic part of their illness trajectory. Nurses need to attend carefully also to discomforts other than pain.

Experiences of donor families after consenting to organ donation: a qualitative study.

AIM: The aim of this study was to investigate the experience of Norwegian donor families during organ donation after brain death. METHODS: This was a qualitative study using personal interviews. Twenty donor-family members from thirteen different situations were interviewed about their experience of being a close relative in an organ donation situation. The principles of qualitative content analysis were used. FINDINGS: An experience of strain caused by the organ donation situation was identified. Lack of comprehension and awareness of the process of organ donation contributed to this, and continuing information after the consent was given appeared to be necessary. Reconciliation with the decision of organ donation and the subsequent situation was gained through understanding the organ donation process, through recognition of the increased strain and through satisfaction resulting from the contribution made by organ donation. Healthcare personnel were key persons in contributing to such understanding and recognition. CONCLUSION: When attending to families in an organ donation situation, the focus must be on ensuring comprehension of the situation both through information provided in the hospital and during follow-up. It seems essential to arrange for a period of parting that can contribute to reconciliation, and to offer follow-up according to individual needs.