Humanizing and dehumanizing intensive care: Thematic synthesis (HumanIC).

BACKGROUND: Critical illness and the intensive care unit can be a terrifying experience to patients and relatives and they may experience the extreme life-saving measures as dehumanizing. Humanizing intensive care is often described as holism or dignity, but these abstract concepts provide little bodily resonance to what a humanized attitude is in concrete situations. OBJECTIVE: To explore what contributes to patients' and relatives' experience of intensive care as humanized or dehumanized. DESIGN: Thematic synthesis. MATERIALS: Findings from 15 qualitative papers describing patients' and/or relatives' perceptions of humanizing or dehumanizing care. METHODS: A systematic literature search of PubMed, CINAHL, Scopus and EMBASE from 1 January 1999 to 20 August 2022 identified 16 qualitative, empirical papers describing patients' and relatives' experiences of humanizing or dehumanizing intensive care, which were assessed using Critical Appraisal Skills Programme Qualitative Checklist, 15 papers were included and analysed using Thematic Synthesis and Ricoeur's model of the text. FINDINGS: Intensive care was humanized when patients felt connected with healthcare professionals, with themselves by experiencing safety and well-being and with their loved ones. Intensive care was humanized to relatives when the patient was cared for as a unique person, when they were allowed to stay connected to the patient and when they felt cared for in the critical situation. CONCLUSION: Patients and relatives experienced intensive care as humanized when healthcare professionals expressed genuine attention and supported them through their caring actions and when healthcare professionals supported patients' and relatives' opportunities to stay connected in the disrupted situation of critical illness. When healthcare professionals offered a connection to the patients and relatives, this helped them hold on and find meaning. PATIENT OR PUBLIC CONTRIBUTION: No patient and public contribution.

Nursing staff facilitate patient participation by championing the patient's perspective: An action research study in spinal cord injury rehabilitation.

INTRODUCTION: Persons with spinal cord injury have experienced a life-changing event, and they need to engage in the rehabilitation process to adjust to their current situation and future living conditions. Due to the highly contextual and varying psychological and physical ability to participate from patient to patient during rehabilitation, this is difficult for the injured person and for health professionals to support. Therefore, the aim of the study was to develop and facilitate patient participation by engaging nursing staff and from this engagement in the process, disclose methods to support participation. METHODS: The processes conducted were based on an action research approach, from problem identification to the development, test and evaluation of four new nursing initiatives. The initiatives were developed by eight nursing staff members who participated actively as co-researchers in a 2-year study conducted at a Spinal Cord Injury Centre in Denmark from 2016 to 2018. Data evolved from workshops, transcriptions of meetings and written evaluations and was further analysed using Ricoeur's phenomenological-hermeneutic approach. RESULTS: Action research processes facilitated the development of four communicative initiatives and a shift in the nursing staff's support of the patient. In a collaborative process, the nursing staff acted as participants in the patient's rehabilitation. Awareness of the patient's perspective facilitated a caring, attentive and engaged approach from the nursing staff, which promoted rehabilitation tailored to the individual. CONCLUSION: Patient participation was enhanced when nursing staff actively participated in the development of initiatives and a culture supporting a person-to-person approach involving the patient and themselves as equal participants in the collaborative rehabilitation process. PATIENT OR PUBLIC CONTRIBUTION: Eight nursing staff members from the rehabilitation centre participated throughout the study as co-researchers. Patients participated in observations and as informants in interviews during the first phase to identify challenges to patient participation. Patients also participated in testing the nursing initiatives during the action phase (Phase 3). Furthermore, a former patient was a member of the advisory board.

"Humanizing intensive care: A scoping review (HumanIC)".

Significant scientific and technological advances in intensive care have been made. However, patients in the intensive care unit may experience discomfort, loss of control, and surreal experiences. This has generated relevant debates about how to humanize the intensive care units and whether humanization is necessary at all. This paper aimed to explore how humanizing intensive care is described in the literature. A scoping review was performed. Studies published between 01.01.1999 and 02.03.2020 were identified in the CINAHL, Embase, PubMed, and Scopus databases. After removing 185 duplicates, 363 papers were screened by title and abstract. Full-text screening of 116 papers led to the inclusion of 68 papers in the review based on the inclusion criteria; these papers mentioned humanizing or dehumanizing intensive care in the title or abstract. Humanizing care was defined as holistic care, as a general attitude of professionals toward patients and relatives and an organizational ideal encompassing all subjects of the healthcare system. Technology was considered an integral component of intensive care that must be balanced with caring for the patient as a whole and autonomous person. This holistic view of patients and relatives could ameliorate the negative effects of technology. There were geographical differences and the large number of studies from Spain and Brazil reflect the growing interest in humanizing intensive care in these particular countries. In conclusion, a more holistic approach with a greater emphasis on the individual patient, relatives, and social context is the foundation for humanizing intensive care, as reflected in the attitudes of nurses and other healthcare professionals. Demands for mastering technology may dominate nurses' attention toward patients and relatives; therefore, humanized intensive care requires a holistic attitude from health professionals and organizations toward patients and relatives. Healthcare organizations, society, and regulatory frameworks demanding humanized intensive care may enforce humanized intensive care.

Helpful factors in a healthcare professional intervention for low-back pain: Unveiled by Heidegger's philosophy.

Low-back pain can be invalidating physically as well as mentally. Despite professional help to treat and prevent low-back pain, the pain often persists, and so do the problems related to low-back pain. An intervention that made it possible for a significant part of patients with low-back pain to improve health and well-being raised the question: Why was it possible to help some and not others? The aim of the present paper was to achieve a deeper understanding of factors patients experienced as helpful in professional support related to low-back pain. This was explored using a hermeneutic-phenomenological approach while analysing 20 interviews with patients with low-back pain purposively chosen interviews conducted in relation to the intervention. An analysis was made using Ricoeur's interpretation theory. Data on both positive and negative experiences were read and reflected upon. We found that healthcare professionals' adoption of a narrative approach facilitating the patient's perspective was perceived as helpful. Patients experienced this as being taken seriously; an experience that could be explained at a deeper, more nuanced level using Heidegger's philosophy. Facilitating the patient's perspective was conditional not only on the professional obtaining access to the patient's perspective but also on understanding and acknowledging the patient's existence. The challenge for healthcare professionals in this respect is to bridge the gap between the consultation's fact-focused concern with the medical implications of low-back pain and the patient's concern with the implications low-back pain has for his or her personal identity and life. Listening to the patient's perspective in itself supports the subjective recovery process, while also supporting the quality of patient-centred support and strengthening the patient's trust in its helpfulness.

Action research as a catalyst for change: Empowered nurses facilitating patient participation in rehabilitation.

Based on action research as a practitioner-involving approach, this article communicates the findings of a two-year study on implementing patient participation as an empowering learning process for both patients and rehabilitation nurses. At a rehabilitation facility for patients who have sustained spinal cord injuries, eight nurses were engaged throughout the process aiming at improving patient participation. The current practice was explored to understand possibilities and obstacles to patient participation. Observations, interviews and logbooks, creative workshops and reflective meetings led to the development and testing of four new rehabilitation initiatives aimed at enhancing patient participation. This study suggests that skills of critical reflection from action research toolbox shed light on both the notion of patient participation and caring in nursing rehabilitation. By actively involving nurses in research, the knowledge development stems from practice and the solutions therefore became practice-oriented. In addition, the personal and professional development experienced by the involved nurses points to a secondary gain in the form of an analytical and reflective approach to complex issues in relation to patient participation, rehabilitation in general and the individual nurses' sense of professional pride.

Translation, cultural adaptation and psychometric properties of the Ghanaian language (Akan; Asante Twi) version of the Health Literacy Questionnaire.

BACKGROUND: Patients' competencies and resources to manage their own health, which is termed health literacy, is a necessity for better health outcomes. Thus, it is relevant to have a comprehensive health literacy measurement tool suitable for populations of interest. The Health Literacy Questionnaire (HLQ) is a tool useful for health literacy assessment covering nine dimensions/scales of health literacy. The HLQ has been translated and validated in diverse contexts but has so far not been assessed in any country in sub-Saharan Africa. We sought to translate this tool into the most common language used in Ghana and assess its validity. METHODS: We carried out a cross-sectional study using the HLQ concurrently with an assessment of a malaria programme for caregivers with children under 5 years. The HLQ was translated using a systematic translation procedure. We analysed the psychometric properties of the HLQ based on data collected by face-to-face interview of 1234 caregivers. The analysis covered tests on difficulty level of scales, composite reliability, Cronbach's alpha and confirmatory factor analysis (CFA). RESULTS: Cognitive testing showed that some words were ambiguous, which led to minor rewording of the questionnaire. A nine-factor CFA model was fitted to the 44 question items with no cross-loadings or correlated residuals allowed. Given the very restricted nature of the model, the fit was quite satisfactory: χ2 DWLS (866 df) = 17,177.58, p < 0.000, CFI = 0.971, TLI = 0.969, RMSEA = 0.126 and SRMR = 0.107. Composite reliability and Cronbach's alpha were > 0.65 for all scales except Cronbach's alpha for scale 9, 'Understanding health information well enough to know what to do' (0.57). The mean differences between most demographic groups among health literacy scales were statistically significant. CONCLUSION: The Akan-Twi version of HLQ proved relevant in our description of the health literacy levels among the caregivers in our study. This validated tool will be useful to conduct health literacy needs assessments to guide policies addressing such needs. Further work is needed to validate this tool for use in Ghana and similar contexts.

The effect of family-authored diaries on posttraumatic stress disorder in intensive care unit patients and their relatives: A randomised controlled trial (DRIP-study).

BACKGROUND: Critical illness and mechanical ventilation may cause patients and their relatives to experience symptoms of posttraumatic stress, anxiety, and depression due to fragmentation of memories of their intensive care unit (ICU) stay. Intensive care diaries authored by nurses may help patients and relatives process the experience and reduce psychological problems after hospital discharge; however, as patients particularly appreciate diary entries made by their relatives, involving relatives in authoring the diary could prove beneficial. OBJECTIVES: The objective of this study was to explore the effect of a diary authored by a close relative for a critically ill patient. METHODS: The study was a multicenter, block-randomised, single-blinded, controlled trial conducted at four medical-surgical ICUs at two university hospitals and two regional hospitals. Eligible for the study were patients ≥18 years of age, undergoing mechanical ventilation for ≥24 h, staying in the ICU ≥48 h, with a close relative ≥18 years of age. A total of 116 relatives and 75 patients consented to participate. Outcome measures were scores of posttraumatic stress symptoms, anxiety, depression, and health-related quality of life three months after ICU discharge. RESULTS: Relatives had 26.3% lower scores of posttraumatic stress in the diary group than in the control group (95% confidence interval: 4.8-% to 52.2%). Patients had 11.2% lower scores of posttraumatic stress symptoms in the diary group (95% confidence interval: -15.7% to 46.8%). There were no differences between groups in depression, anxiety, or health-related quality of life. CONCLUSION: A diary written by relatives for the ICU patient reduced the risk of posttraumatic stress symptoms in relatives. The diary had no effect on depression, anxiety, or health-related life quality. However, as the diary was well received by relatives and proved safe, the diary may be offered to relatives of critically ill patients during their stay in the ICU.

Structure and content of diaries written by close relatives for intensive care unit patients: A narrative approach (DRIP study).

AIM: To investigate structure and content of a nurse prompted diary written by relatives for intensive care unit (ICU) patients. DESIGN: A narrative analysis of ICU diaries. METHODS: From September 2015-August 2016, 12 diaries authored by 12 relatives for 12 ICU patients were sampled at 3-4 months post-ICU discharge. We used Ricoeur's hermeneutical phenomenology as a framework for a narrative analysis of the diaries. The first step was naïve reading, followed by structural analysis exploring the internal relations of the text. The structural analysis was broadened by exploring narrative structures. The last step was critical interpretation of the findings. FINDINGS: The diaries had a clear narrative structure; the diary-timeline consisted of: Pre-ICU phase, Early ICU phase, Culmination, Recovery and Post-ICU reflection. Three themes described the content of the diary: Struggling to get the story right for the patient; striving to understand what was happening and longing to re-establish a connection with the patient. Keeping a diary was perceived by the relatives as a challenging but rewarding task. CONCLUSION: The diary had the potential for reflection and a deeper understanding of the ICU stay. The diary served as a locus for patient and relatives to connect or re-connect, but some diaries might be too personal and emotional to share with the patient. Future research needs to explore advantages and disadvantages of ICU diaries authored by relatives.

Finding the Way Forward: The Lived Experience of People With Stroke After Participation in a Complex Psychosocial Intervention.

Stroke patients' well-being is threatened after stroke. A psychosocial intervention was developed for Norwegian stroke patients living in the community. Eight individual sessions between people with stroke and a trained health care professional were conducted 1 to 6 months post-stroke with one group of participants and 6 to 12 months post-stroke with another group. Subsequently, 19 of these stroke patients were interviewed to gain an in-depth understanding of their lived experience of the influence of the intervention on their adjustment process. Interview texts were analyzed using Ricoeur's interpretation theory. Two participants did not personally find the intervention useful. The remaining participants greatly appreciated dialogues with the empathetic intervention personnel, feeling free to discuss their fears and worries. The intervention raised these participants' awareness of their needs and resources. They were guided to resume their everyday life and adopt a future-oriented attitude. The intervention facilitated their meaning-making endeavors and post-stroke adjustment.

Nursing roles and functions addressing relatives during in-hospital rehabilitation following stroke. Care needs and involvement.

RATIONALE: In the last decades, length of stay of in-hospital rehabilitation of patients with stroke has been significantly reduced. Health authorities expect relatives to be at disposal to convey the knowledge of everyday life and to provide emotional as well as practical support in relation to the patient. Caregivers require nurse assistance, support and to be seen as an essential partner in the care giving process. However, the nurses do not perceive that teaching of relatives is a task they should routinely undertake. This might indicate an ambiguity between the relatives' expectations and the actual contribution from nurses. AIM: This study describes nurses' experienced roles and functions addressing the relatives of patients with stroke during in-hospital rehabilitation. METHODOLOGICAL DESIGN: A phenomenological hermeneutic approach influenced by Paul Ricoeur. In a secondary analysis focus group, interviews of 19 randomly selected nurses from three different hospital settings were interpreted in three levels. The study was conducted in accordance with the ethical guidelines for nursing research in the Nordic countries. FINDINGS: The nurses expressed that they address the patient and the relatives and support the interaction between the patient and the relatives. Four themes occurred: the changed lives of relatives; shared life after stroke; noncooperating relatives; time for the relatives. CONCLUSION: Nurses experience their roles and functions addressing relatives after stroke as crucial, challenging and multifaceted. They acknowledged care needs of the relatives in their own right by addressing the relatives' vulnerability during in-hospital rehabilitation characterised by an existential threat to the physical as well as the shared life. The focus on the needs of relatives considering their expected future role was experienced as conflicting with restricting time frames and a healthcare system focusing on the individual patient.

The effect of diaries written by relatives for intensive care patients on posttraumatic stress (DRIP study): protocol for a randomized controlled trial and mixed methods study.

BACKGROUND: Critically ill patients and their relatives have complex needs for support during their stay in the intensive care unit (ICU) and the post-ICU rehabilitation period. Diaries written by nurses have proven beneficial for patients and relatives, preventing post-traumatic stress, anxiety and depression and helping patients and families find meaning. Actively involving relatives in writing a diary for critically ill patients is a new approach to helping relatives and patients cope; however, research is limited.The aim of this study is to test the hypothesis that a diary written by a close relative of a critically ill patient will reduce the risk of developing symptoms of post-traumatic stress disorder (PTSD) in the patient and relatives at 3 months post-ICU. Furthermore, the aim is to explore the perceptions and use of the diary and describe the diary content and structure. METHOD: The intervention consists of a hard-cover notebook that will be given to a close relative to write a diary for the critically ill patient while in the ICU. Guidance will be offered by ICU nurses on how to author the diary. The effect of the intervention will be tested in a two-arm, single-blind, randomized controlled trial, which aims to include 100 patient/relative pairs in each group. The primary outcome studied is symptoms of post-traumatic stress (PTSS-14). Secondary outcomes are scores on anxiety and depression (HADS) and the Medical Outcomes Study Questionnaire Short Form 36 (SF-36). The narrative structure and content of the diary as well as its use will be explored in two qualitative studies. DISCUSSION: The results of this study will inform ICU nurses about the effects, strengths and limitations of prompting relatives to author a diary for the patient. This will allow the diary intervention to be tailored to the individual needs of patients and relatives. TRIAL REGISTRATION: NCT02357680. Registered September 3, 2015.

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.

How diaries written for critically ill influence the relatives: a systematic review of the literature.

BACKGROUND: Diaries written by nurses for the critically ill patient helps relatives cope and support the patient. When relatives participate in writing a diary for the critically ill, patients appreciate it. Furthermore, the diary may reduce post-traumatic stress disorder, anxiety and depression in patients and relatives. AIM: To explore how relatives perceive reading and writing in the diary and how it affects their well-being. SEARCH STRATEGIES: A systematic search was carried out in the databases PubMed, Embase, CiNAHL and PsycINFO and supplemented by a citation search in Scopus on four-selected articles. Finally, 10 articles were included in this review structured by the Matrix method. INCLUSION CRITERIA: (a) Original scientific work, (b) relatives participation and experience of the diary as subject and (c) diaries studied in an intensive care unit setting. FINDINGS: Relatives were given instructions on how to write in the diary. They expressed strong feelings in the diary in a very different way than health care staff. The relatives used the diary themselves to gain understanding and to cope. The diary has been shown to prevent post-traumatic stress symptoms. CONCLUSION: The relatives express their love for the patient, when they author the diary and this may be beneficial to the relatives as it helps them cope and support the patient. The organized account of the time in the intensive care unit in the diary may explain the diary's ability to reduce the occurrence of post-traumatic stress disorder; however, further research is needed to confirm this. How relatives interact through writing and reading a diary, originally intended for the patient, is unclear. RELEVANCE TO CLINICAL PRACTICE: Providing relatives with a diary may help them cope. However, caution should be taken as possible adverse effects related to the interaction between relatives in the diary may not yet be known.

Relatives perception of writing diaries for critically ill. A phenomenological hermeneutical study.

BACKGROUND: Diaries written by nurses for the critically ill patient help the relatives cope and support the patient. Relatives may participate in writing a diary for the critically ill and when they do this is appreciated by the patients. However, the relative's perception of writing a diary has not previously been explored. AIM: To explore how relatives perceive writing a diary for the critically ill patient. METHOD: In a phenomenological-hermeneutic study building on the theory of Ricoeur interviews with seven relatives were conducted and interpreted. FINDINGS: When relatives wrote a diary for the critically patients, they experienced that writing and reading the diary allowed for the unloading of emotions and expression of feelings. Writing a diary was a meaningful activity while enduring a situation of uncertainty and furthermore it created a distance that allowed understanding of the critical situation. CONCLUSION: Involving relatives in writing a diary may support relatives and help them cope with the critical situation. RELEVANCE TO CLINICAL PRACTICE: Relatives are distressed and struggle to understand what is happening during the patient's course of illness. Involving relatives in writing a diary for the critically ill could be one way to meet their needs in the critical situation.

Competing discourses as barriers to change in rehabilitation nursing: a discourse analysis.

Introduction: The power of action research to create change by anchoring research results in practice was challenged in an action research project at a specialized rehabilitation unit for persons with acquired spinal cord injury. Despite the co-researchers' new insights, approaches, and actions supporting patient participation, it was not possible to change the basic conditions for the practicing of nursing. We aimed to raise awareness of the mechanisms that govern barriers by exploring these barriers as experienced by nurses in their effort to change their practice to improve patient participation. Method: We used Fairclough's critical discourse analysis drawing on Foucault's practical systems; ethics (identity, relation to oneself), power (action, relation to others), and knowledge (representation, aspects of the world), which he combines with discourse-analytical concepts. Results: Our discourse analysis of the empirical data at micro-level uncovers the nature of barriers to change in practice. In addition, our analysis at macro-level unveils how these practices are embedded in larger historical, societal, and institutional discourses. This identified two current discourses: a biomedical discourse and a biopsychosocial discourse. In the light of these two discourses, the nurses at micro-level saw themselves as strong agents for the best rehabilitation by acting in accordance with the biopsychosocial discourse. But they were unable to find the time and space to do so due to tasks, structures, and practices specified by an organization dominated by the biomedical discourse.

Ten years of living with an injured spinal cord: A qualitative longitudinal study.

Purpose: Rehabilitation and recovery following spinal cord injury often implies a fundamentally changed life. The aim of this study was to explore the process of living with spinal cord injury for 10 years to identify which factors were most decisive for living a fulfilled life. Materials and methods: The present study was a 10-year longitudinal qualitative study based on Ricoeur's hermeneutic-phenomenological approach to explore and interpret people's experiences of life during the first 10 years after they had suffered a spinal cord injury. Interviews were conducted with 10 people during the first year and then again after two, five and 10 years. Results: The process over 10 years showed that a satisfying life can be led despite limitations caused by the damaged spine by balancing possibilities and the life wished for. Reduced body function did not have to hinder people from living a satisfying life. Bodily issues can move into the background when new skills and routines are developed. This enabled backgrounding body conditions, letting other matters foreground. Thus, life can be experienced as good and can resemble the lives of other people of the same age, though strains and struggles were an integrated part of every activity. However, the new normal was disturbed when bodily conditions could not be kept stable or worsened due to illness, often related to the damaged spine. If this challenged the new way of living, the body foregrounded and became the primary focus for effort and attention, and the process of balancing possibilities and the life wished for had to be repeated. Conclusions: Life 10 years after spinal cord injury can be experienced as good despite limitations, partly resembling life lived by other same-aged people. Having stable bodily conditions allowed other matters to foreground. This was important to the process of reconciling oneself to the situation and balancing possibilities and the life wished for.

What Does It Take for Research to Be Rehabilitation Research?

Six recommendations to facilitate rehabilitation research and supplement existing research practices were identified. Rehabilitation practice requires research addressing different long-term multi-faceted needs and perspectives of end users, including service users, professionals, politicians, and administrators. Research in rehabilitation should therefore integrate different research traditions and methods. Rehabilitation research with a broad focus is sparse, and most of the research takes its starting point in the biomedical research tradition. Through a nominal group process, we developed recommendations to emphasize important issues in rehabilitation research.

Rehabilitation after spinal cord injury and the influence of the professional's support (or lack thereof).

AIM AND OBJECTIVES: To investigate how spinal cord injured patients struggle with their rehabilitation and how they feel that the professionals influence this process. BACKGROUND: Rehabilitation after a spinal cord injury is a long and arduous process during which the patient needs much support. Some patients lack adequate support from the professionals. This makes it pertinent to investigate the processes patients go through to get on with their lives and the influence professionals have. DESIGN: A phenomenological-hermeneutic study with a narrative approach using Ricoeur's theory. METHOD: A purposeful and consecutive sample of 12 newly injured, adult Danish-speaking patients previously living a normal life were observed 7-12 times and interviewed six or seven times over two years. RESULTS: The patients regained meaning and got on with life through resolute fighting for a meaningful life. We found three patterns of fight; the patients fought with themselves together with the professionals (pattern I). If consensus about the goals and pathway broke down and was not re-established, this fight could turn into a fight against the professionals (pattern II). This would, in turn, cause the patients to fight against themselves. A third pattern (III) was that the patients turned away, either going their own way or suppressing themselves by adapting to the professionals' views. In either case, the patients would feel being left on their own. CONCLUSION: When the patient and professionals agreed on the way forward, the patient experienced the professionals as supportive. However, if the patient's goals were not consistent with the professionals' views, the patient felt that the professionals withdrew their support. RELEVANCE TO CLINICAL PRACTICE: If the professional were able to maintain consensus with the patient, they contributed to the patient's process of regaining meaning.

Living a Meaningful Life While Struggling with Mental Health: Challenging Aspects Regarding Personal Recovery Encountered in the Mental Health System.

Based upon academic and clinical experience from Denmark, this article aims to highlight international research-based knowledge concerning challenging aspects about the understanding and implementation of recovery-oriented practice. Three key points are located: (a) An integrative biopsychosocial approach considering both the clinical and personal recovery perspectives is relevant for research and practice. (b) Barriers in implementing a recovery-oriented approach include both individual and systemic challenges. This is well documented in the research-based literature, highlighting the need for changes. (c) A shift from professional control to a service-user orientation is seen as crucial. Examples of a positive shift are seen, helping the health professionals in their development and practicing of skills and competences through education and personal formation. Within these perspectives, a paradigm shift from a one-dimensional biomedical approach to a biopsychosocial approach is suggested. Instead of focusing on rapid stabilisation and symptom relief as a clinical outcome, a humanistic approach building on social- and person-oriented values is fundamental for social and personal recovery leading to a meaningful life.

Effect of relatives' intensive care unit diaries on post traumatic stress in patients and relatives (DRIP-study): A mixed methods study.

AIM: To explore the relationship between psychological distress and diary sharing in patients and relatives, by investigating: 1) diary usage, 2) diary perception and 3) symptoms of psychological stress. DESIGN: Convergent mixed methods study. SETTING: Two intensive care units using patient diaries written by relatives with nurse guidance and shared with the patient after discharge. DATA: Self-reported scores of symptoms of posttraumatic stress, anxiety, depression and diary usage were crossed with qualitative description of diary usage and diary perception in 10 patients and 11 relatives. RESULTS: Most relatives expressed positive perceptions of diary usage; sharing the diary with the patient was related to fewer symptoms of posttraumatic stress. Patients had a positive perception of diary sharing, but symptoms of posttraumatic stress were unchanged. CONCLUSION: Reflecting on the tribulations of critical illness and later sharing reflections with the patient were related to lower rates of posttraumatic stress in relatives, suggesting that the act of writing and sharing a diary could have a protective effect. Delayed diary sharing did not have the same effect on patients but might enhance support between relatives and patients.