Older patients' recovery following intensive care: A follow-up study with the RAIN questionnaire.

The aim was to investigate older patient recovery (65 years+) up to two years following discharge from an intensive care unit (ICU) using the Recovery After Intensive Care (RAIN) instrument and to correlate RAIN with the Hospital Anxiety and Depression Scale (HAD). METHODS: An explorative and descriptive longitudinal design was used. Eighty-two patients answered RAIN and HAD at least twice following discharge. Demographic and clinical data were collected from patient records. RESULTS: Recovery after the ICU was relatively stable and good for older patients at the four data collection points. There was little variation on the RAIN subscales over time. The greatest recovery improvement was found in existential ruminations from 2 to 24 months. A patient that could look forward and those with supportive relatives had the highest scores at all four measurements. Having lower financial situation was correlated to poorer recovery and was significant at 24 months. The RAIN and HAD instruments showed significant correlations, except for the revaluation of life subscale, which is not an aspect in HAD. CONCLUSION: The RAIN instrument shows to be a good measurement for all dimensions of recovery, including existential dimensions, which are not covered by any other instrument.

Patients' participation in and evaluation of a follow-up program following intensive care.

BACKGROUND: Patients' difficulties following critical illness and the willingness of intensive care units (ICU) to take an expanded responsibility during the recovery period have led to the development of different follow-up programs. The aim of this study was to explore and describe patients' participation in and evaluation of a follow-up program at a nurse-led clinic (NLC). METHODS: Patients with a length of stay ≥72 h, discharged from the ICU, participated in a follow-up program based on three contacts, as a visit to the NLC, telephone contact, ward visit or as an indirect contact, during a 6-month period. A specially developed database recorded information regarding patients' participation and questionnaires were used to obtain patients' views of the follow-up program. RESULTS: Of 96 study patients, 51% visited the NLC once or twice. These patients were younger (P<0.001) and had lower Acute Physiology and Chronic Health Evaluation II (P=0.017) compared with those who did not visit the clinic. The most common reason for not visiting the clinic was not enough strength, chiefly physical. In the evaluation, patients answered that they received advice and information, an opportunity to talk, increased knowledge and re-evaluated memories and experiences from the ICU stay. Patients appreciated the follow-up and expressed gratitude to the competent and obliging staff. CONCLUSION: The current follow-up program, adjusted to individual patients' conditions and needs in terms of different types of contacts and continuity, was found to be of great value. Effects of the program other than the patient perspective are also relevant to evaluate.

Relatives' experiences of visiting a conscious, mechanically ventilated patient--a hermeneutic study.

BACKGROUND: In recent years, light or no sedation has become a common approach to invasive mechanical ventilation in patients with respiratory distress. The experience of visiting a conscious patient receiving mechanical ventilation in the ICU has to our knowledge not yet been investigated. AIM: The aim of the study was to describe the meaning attributed by relatives to their experiences of meeting, seeing and communicating with a patient cared for on a mechanical ventilator while conscious. METHOD: This study used a prospective, exploratory design comprising interviews with ten relatives conducted on two occasions; in connection with their visits to a patient cared for on a ventilator while conscious and approximately a week after the end of intensive care. The data were analysed by means of hermeneutic interpretation to obtain a deeper understanding of relatives' experiences. RESULTS: Striving to achieve contact with the patient was the most important aspect of being a close relative of a patient receiving ventilator treatment while conscious and was described by four main themes: feeling ambivalent towards consciousness; feeling ambivalent towards sedation; feeling dependent on the carer and being disappointed; and suppressing own suffering and sadness. CONCLUSION: The patients' consciousness enabled the relatives to judge their condition for themselves and enter into contact. This resulted in a sense of being in control but also efforts to suppress own suffering.

Family presence and environmental factors at the time of a patient's death in an ICU.

BACKGROUND: In an intensive care unit (ICU), privacy and proximity are reported to be important needs of dying patients and their family members. It is assumed that good communication between the ICU team and families about end-of-life decisions improves the possibilities of meeting families' needs, thus guaranteeing a dignified and peaceful death in accordance with end-of-life care guidelines. The aim of this study was to explore the circumstances under which patients die in Swedish ICUs by reporting on the presence of family and whether patients die in private or shared rooms. An additional aim was to investigate the frequency of end-of-life decisions and whether nurses and family members were informed about such decisions. METHODS: A questionnaire based on the research questions was completed when a patient died in the 10 ICUs included in the study. Data were collected on 192 deaths. RESULTS: Forty per cent of the patients died without a next of kin at the bedside and 46% of deaths occurred in a shared room. This number decreased to 37% if a family member was present. Patients without a family member at their bedside received less analgesics and sedatives. There was a significant relationship between family presence, expected death and end-of-life decisions. CONCLUSIONS: The results indicate the necessity of improving the ICU environment to promote the need for proximity and privacy for dying patients and their families. The study also highlights the risk of underestimating the needs of patients without a next of kin at their bedside at the time of death.

Patients' subjective symptoms, quality of life and intake of food during the recovery period 3 and 12 months after upper gastrointestinal surgery.

Few studies describe patients' quality of life and their experienced symptoms during the recovery period after having undergone upper gastrointestinal surgery at 3 and 12 months. The aims of this study were to explore patients' quality of life and symptoms preoperatively and at 3 and 12 months following upper gastrointestinal surgery and to describe and compare patients' experiences of appetite, food intake, weight changes, tiredness and sleeping patterns. A descriptive and comparative quantitative design was used. Three instruments were used: the Gastrointestinal Symptom Rating Scale, the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire and the Eating Dysfunction Scale. A questionnaire was used to investigate symptoms such as mood, appetite, sleep, activities and well-being. Twenty-four patients were included in the study. The major results were that anxiety levels and global health status decreased and that patients felt more disappointed after 12 months compared with after 3 months. Four patients at 3 months after surgery and eight patients at 12 months regained their weight compared with the situation before surgery. The contribution of nursing care activities focusing on the importance of food intake and the patients' current and historical medical records in relation to their health status should continue to be examined and researched over a longer period of time.

Changes in patients' need of nursing care reflected in the Zebra system.

During 1995-97, many head nurses stated that they had perceived an increase in patients' need of nursing care. A questionnaire was designed to determine the reasons for this. The purpose of the investigation was to answer two questions, 'What were the reasons for head nurses perception of an increase in patients need of nursing care from 1995 to May 1997?' and, 'Does patient classification in the Zebra system reflect the underlying changes in patients' need of nursing care? The results show that there are several reasons behind changes in the patients need of nursing care. The main reasons are a decreased general level of health among patients and that treatments are more time-consuming. After comparing statistics concerning patient classification with the answers received from the questionnaire, a good level of agreement could be seen in these.

Intensive care unit syndrome/delirium is associated with anemia, drug therapy and duration of ventilation treatment.

BACKGROUND: We have performed a prospective qualitative investigation of the ICU syndrome/delirium; the main parts of which have recently been published. The aim of the present study was to explore the relationship between the ICU syndrome/delirium and age, gender, length of ventilator treatment, length of stay and severity of disease, as well as factors related to arterial oxygenation and the amount of drugs used for sedation/analgesia. METHODS: Nineteen mechanically ventilated patients who had stayed in the ICU for more than 36 h were closely observed during their stay, and interviewed in depth twice after discharge. Demographic, administrative and medical data were collected as a part of the observation study. RESULTS: Patients with severe delirium had significantly lower hemoglobin concentrations than those with moderate or no delirium (P=0.033). Patients suffering from severe delirium spent significantly longer time on the ventilator and at the ICU, and were treated with significantly higher daily doses of both fentanyl (P=0.011) and midazolam (P=0.011) in comparison with those reporting only moderate or no symptoms of delirium. There were no significant differences in the Therapeutic Intervention Scoring System scores, reflecting the degree of illness, between patients with and without delirium. CONCLUSION: The development of the ICU syndrome/delirium seems to be associated with decreased hemoglobin concentrations and extended times on the ventilator. Prolonged ICU stays and treatment with higher doses of sedatives and opioids in patients with delirium appear to be secondary phenomena rather than causes.

Patients' experiences of the recovery period 3 months after gastrointestinal cancer surgery.

It is known that patients who have undergone gastrointestinal surgery as a result of a tumour experience changes in weight and intake of food and fluid. Several studies have highlighted patients' experiences owing to cancer, but there is a lack of knowledge about the recovery period from the patients' perspective. The purpose of this research is to describe patients' experiences of the recovery period 3 months after surgery. Data was collected by inviting four women and six men, between 52 and 84 years of age, to participate in an interview or dialogue 3 months after surgery. The study takes a hermeneutic approach. The framework for interpretation is the theory "Man's search for meaning" and further theories about suffering. The recovery period is characterized by feelings of being "down in the depths", lonely, abandoned and disappointed, but also feelings of support. Some patients regained strength and energy and reached a turning point, while others did not. Patients' suffering is seen as being in limbo, a fight between lack of freedom and freedom, including feelings of hope and doubts.

Clinical signs of ICU syndrome/delirium: an observational study.

Some clinical signs of the intensive care unit (ICU) syndrome/delirium are probably known, but there may be additional signs that can be observed during the care of ICU patients. The aim of this study was to investigate and describe the clinical signs of the ICU syndrome in relation to patients' reactions and behaviour following the second day of their stay in an ICU. A total of 31 patients were observed during the weaning process and in the days following extubation. Informal dialogues between the patient and the observer, using parts of the questionnaire 'Organic Brain Syndrome Scale' were also carried out. The data was structured in a chronological order and consists of descriptions of patients' behaviour and reactions, together with events, occurrences and environmental circumstances. It was found that the patients showed a great variety of clinical signs that could be related to the ICU syndrome. Such signs were the quality, ability and divergence of speech; talking, movements, bodily position and facial expressions. Several patients also related unreal experiences only occasionally, while others experienced them during longer periods. The clinical signs did not seem to be separate phenomena but were inter-connected and part of a progression, and, therefore must be seen in the overall context and situation. Longer periods of observation and repeated interaction with patients are necessary in order to be aware of onset and clinical signs of the ICU syndrome.

No going back: narratives by close relatives of the braindead patient.

The aim of this narrative study was to illuminate the meaning of being a relative of a patient diagnosed as brain dead. This has so far been explored only to a limited extent. By phenomenological-hermeneutic analysis of 14 narratives, a chronological narrative in 4 steps was identified: the disquieting event; the uncertain vigil; the arduous struggle; and the difficult road ahead. From the analysis, the metaphor of an inner journey emerged, starting from a life situation taken for granted and experienced as safe, and moving towards the unknown, the unfamiliar. During the journey, a series of events of decisive importance in the relative's life were found to take place. Major stages along the road were efforts made to comprehend the reality of death, saying farewell and taking leave of the loved one. The importance of the ICU nurse taking part in the relative's inner journey is discussed in relation to Eriksson's theory of suffering and Martinsen's theory of caring. Implications and suggestions for nursing care activities are discussed.

The nearest and dearest: a lifeline for ICU patients.

This study was designed to examine, describe and elucidate patients' experiences of the presence and visits of the nearest and their participation in the care process during their stay in the ICU. Five patients, three men and two women, were interviewed for about one hour each. A hermeneutic approach was used when the texts from the interviews were interpreted and analysed. The theoretical frame of interpretation was based on Tillich's theory concerning 'The courage to be' and Eriksson's theory on 'Suffering'. It was found that suffering from severe disease or injury results in not only a threat against the person as an individual, but also against the individual as a part in the world, with consequent feelings of estrangement and the fear of meaninglessness. The threat can, however, be neutralized by the nearests' presence and visits. These represent fellowship, togetherness and participation and thus can help to maintain the patient's identity and individuality. By experiencing this, patients as individuals may be able to affirm themselves and their 'courage to be' will be given strength and support.

On the use of narratives in nursing research.

On the use of narratives in nursing research Narratives have always been a path to knowledge in nursing care but are a recent element within nursing research. Therefore, this article deals with the narrative and its use within nursing research. First, the use of narratives in nursing care and nursing research is examined. Second, Paul Ricoeur's narrative theory with its dimensions of interpretation, time, action and ethics is presented as a possible methodological basis. Third, the use of Ricoeur's narrative theory in nursing research is examined, showing that, at present, support mainly comes from Ricoeur's text interpretation theory. Finally, a nursing research approach to the narrative, based on the life-world, is suggested.

Patients' and relatives' opinions and feelings about diaries kept by nurses in an intensive care unit: pilot study.

The underlying aim of this study was to obtain knowledge about the questions which could be of interest for a qualitative interview study, and for the planning and construction of a comparative study. The immediate aim was, however, to investigate whether the diary was of importance to patients after their discharge from the ICU or for relatives, following patients' deaths in the ICU. A diary was kept for nine months concerning ten patients together with eight patients who later died in the ICU. All of the ten patients, and four of the eight deceased patients' relatives, answered a questionnaire consisting of five close-ended and two open-ended questions. The participants were encouraged to comment upon all the questions. All participants read the diary. Seven patients stated that it helped them to remember their ICU stay and two that it did not. It helped them to re-live and come to terms with their serious illness/injury and recall what had happened. For those who could not recollect their ICU stay, the diary helped them to remember 'the lost time'. All the relatives except one stated that it helped them to return and adjust to everyday life; made it easier to accept what had happened; and to understand the seriousness of the patient's injury or disease.