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Effect of attachment styles of individuals discharged from an intensive care unit on intensive care experience
Journal of Critical Care (2012) 27, 103.e7–103.e14
Effect of attachment styles of individuals discharged from an intensive care unit on intensive care experience Nurten Kaya PhD, BSN Department of Fundamentals of Nursing, Istanbul University Nursing Faculty, Sisli/Istanbul, TURKEY 34381
Keywords: Attachment theory; Intensive care experience; Health status
Abstract Introduction: The present study was conducted as a cross-sectional type to examine the effect of attachment styles of individuals discharged from an intensive care unit (ICU) on intensive care experience and health status. Methods: The population of the study included patients discharged from the ICU in a university hospital. The sample included 108 patients who were selected via simple random sampling method. Data were collected using a Demographic Information Questionnaire, Intensive Care Experience Questionnaire, the Relationship Scales Questionnaire, and Acute Physiology and Chronic Health Evaluation II system. In the analysis of data, frequency, percentage, mean, standard deviation, minimum and maximum values, and Mann-Whitney U, Kruskal-Wallis, Bonferroni-adjusted Mann-Whitney, and Spearman ρ correlation tests were used. Results: A significant difference in the awareness of surroundings subscale for attachment styles was noted (χ2 = 10.820, P ≤ .01). Moreover, participants' attachment styles (fearful, preoccupied, and dismissing) and intensive care experience were significantly correlated. A significant correlation was found between participants' secure attachment style points and Acute Physiology and Chronic Health Evaluation II score during discharge from the ICU (r = 0.322, P = .001). Conclusion: Individuals' attachment styles should be taken into consideration when planning and implementing the nursing care and treatment of individuals hospitalized in an ICU. © 2012 Elsevier Inc. All rights reserved.
1. Introduction Attachment has been defined as an emotional bond between 2 individuals based on the expectation that one or both members of the pair will provide care and protection in times of need [1-4]. Attachment styles are influential on the behaviors of the individuals who are in relationships with one another and also influential in obtaining satisfaction from their relationships, in the level with which the individuals are affected by the problems experienced in E-mail address: [email protected]. 0883-9441/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jcrc.2011.05.020
relationships, and in coping with these problems [1,5-8]. This study was conducted to determine the effect of attachment styles of individuals discharged from an intensive care unit (ICU) on intensive care experience and health status.
1.1. The intensive care experience Experiences of critically ill patients are an important aspect of the quality of care in an ICU [9]. They can be perceived as stressful, particularly when a person is removed from the safety of his/her home and sent to an ICU, an
103.e8 environment that can be experienced as unfamiliar, strange, and frightening [10,11]. Strahan and Brown [12] described the stressors that threaten the patient in the ICU. These include (a) physical response: disturbances of sleep, thirst, pain, and weakness; (b) environmental stressors: inability to distinguish day from night and feeling of being trapped and tied down by equipment; (c) emotional disturbances: impaired cognitive functioning, worries, anxieties, and fear; and (d) communication difficulties: inability to talk when receiving mechanical ventilation [12]. Adult attachment style, as a personal trait, has gained popularity over the past years, and it is believed that it may influence individuals' intensive care experiences.
1.2. Adult attachment theory Originally formulated by John Bowlby [2-4], attachment theory postulates that an attachment system has evolved with birth to ensure an infant's proximity to a caring and protective caregiver. Bowlby [13] defined attachment as “the propensity of human beings to make strong affectional bonds to particular others.” Main [6] has suggested that early attachment behaviors, such as crying and smiling, were innate, whereas later attachment behaviors reflect organized and conditioned strategies for maintaining closeness and security with the attachment figure. Bartholomew and Horowitz [1] have advanced a 4-category model of adult attachment (secure, fearful, preoccupied, and dismissing) that correspond to Bowlby's original working models of the self and others. According to Bartholomew and Horowitz [1], secure individuals (who have positive models of both self and others) are hypothesized to experience a general comfort with closeness and trust in others, and fearful individuals (who have negative models of both self and others) are hypothesized to avoid close relationships because they fear rejection. Preoccupied individuals (who have a negative self model but a positive model of others) are hypothesized to have an intense desire for emotional intimacy coupled with a heightened concern about being rejected, whereas dismissing individuals (who have a positive model of self but a negative model of others) are hypothesized to stress the importance of independence and self-reliance over close relationships [5,8,14]. Attachment styles, which develop during infancy and childhood, may change over time. They may be influenced by some factors such as psychological, sociocultural, and environmental [15,16] and may be involved in several circumstances including the way an individual responds to treatment and how he/she adapts to new environments.
1.3. Clinical and the intensive care experience relevance of adult attachment theory Attachment has also been discussed by Johnson [17] and Roy [18] in nursing theories. Johnson [17] and Roy [18]
N. Kaya claim that attachment styles should be taken into consideration when assessing a patient's behavior and when planning, implementing, and evaluating the provided care [19-24]. Moreover, some studies in the literature adduce that attachment styles are linked to a number of clinically relevant phenomena. These include quality of intimate relationships, depression, postnatal depression, self-esteem, anger and hostility, communication and marital satisfaction, career choice and satisfaction, eating disorders, psychosis, borderline personality disorder, and sexual and health behaviors [6,7,25-39]. This body of literature suggests a potential effect of attachment styles on adaptation to the environment and the health status. Based on this insight, attachment styles of individuals hospitalized in ICUs seem to be a potentially key factor affecting their adaptation to the unit and/or their health status. Therefore, the hypothesis of the study was established as “There are associations between attachment styles and intensive care experiences and health status.” If such a correlation exists, a care and treatment planned by taking into consideration specific attachment styles of individuals would contribute to a swift and uncomplicated health status.
2. Materials and methods 2.1. Purpose and research questions This research was carried out with a cross-sectional design to determine the effect of attachment styles of individuals discharged from an ICU on their ICU experience and health status. Research questions were as follows: • What are the attachment styles of individuals discharged from an ICU? • What are the ICU experiences of individuals discharged from that unit? • Do the attachment styles of individuals discharged from the ICU influence their intensive care experiences and health status?
2.2. Participants and setting The population of the research composed of individuals discharged from the ICU of a university hospital. The number of subjects to be included in the sample was calculated by taking into account the 2008 data of the ICU: 1074 patients had been admitted to this unit in 2008, and 882 of these patients were either discharged or transferred to other health care facilities. The sample size was calculated using the “sample size estimation with a known population” method. The number of individuals forming the sample population was taken as 882. In addition, based on the data from a study by Demir et al [39], a standard deviation of 13.93 was used for Intensive Care Experience Questionnaire
Attachment styles of individuals discharged from an ICU
103.e9
(ICEQ). Accordingly, the results of a study conducted with a 98-person sample group would reflect a 0.02 error rate and 0.95 confidence interval. A total of 108 subjects were included in the study; considering a possible decrease in the number of participants during the study, for example, because of death or withdrawal, 10 additional subjects were also included as reserve. The sample was planned according to simple random sampling method, using the inclusion criteria listed below:
Questionnaire uses 17 items to create continuous subscales of attachment style categories. The RSQ items consists of 5point Likert scales that measure the extent to which each item statement represents the respondent's feelings about close personal relationships. Four attachment style domains corresponding to the relationship style domains include the following: secure, fearful, preoccupied, and dismissing. The continuous scores, which reflect the 4 attachment styles, are obtained by adding the questions that are aiming to measure these styles and by dividing this total by the number of questions in each of the subscales. Thus, the scores from the subscales may range between 1 and 5. Continuous scores that are achieved by using this method are also used for grouping the participants by attachment styles. Each participant in the course of grouping is appointed to the attachment category in which he/she had the highest score. Part 4. The Acute Physiology and Chronic Health Evaluation II is a severity of disease classification system [43], one of the several ICU scoring systems. The original APACHE developed by Knaus et al [44] in 1981 showed a positive correlation with hospital mortality and length of hospital stay in an ICU. It used the worst record of 34 physiological parameters measured in the first 24 hours after hospital admission, with class allocation of patients to broad categories of illness severity based on simple criteria for the evaluation of chronic ill health. A refined version, APACHE II, was introduced in 1985, which was used as an ICU admission score [43]. These were then reduced to 12 routine physiologic measurements (APACHE II). Up to 4 points are assigned to each physiological variable according to its most abnormal value during the first 24 hours in intensive care. Points are also assigned for age, history of severe clinical conditions, and surgical status. The total number of points gives a score ranging from 0 to 71, with an increasing score representing a greater severity of illness. Studies showed that the APACHE II scoring system is not only useful in predicting mortality and length of hospital stay in critically ill patients but is also helpful in monitoring treatment progress, comparing therapeutic efficacy, deciding treatment withdrawal, and comparing performance in different centers [45]. Therefore, APACHE II was used in the present study to examine the associations between attachment style and health status.
- Ages 20 to 65 years - Hospitalization in the ICU for a minimum of 24 hours - Being free from any communication problems and sensory defects - Voluntary decision to participate in the study
2.3. Instruments A questionnaire made up of 4 parts was used in the study: Part 1. A structured questionnaire for examining patients' demographic details (sex, age, marital, educational, and economic status) and clinical variables (type of ICU admission, mechanic ventilation status, length of ICU stay, previous intensive care experience history, and Acute Physiology and Chronic Health Evaluation II [APACHE II] score during admission to ICU and at the time of discharge from ICU) were used. The questionnaire was developed by the researcher in light of the literature. Part 2. Turkish version of ICEQ was used to determine patients' intensive care experiences. The ICEQ has been developed by Rattray et al [40] to evaluate the experiences of patients staying in ICUs. Reliability and validity of the Turkish version of ICEQ were established by Demir et al. [39]. The Turkish form of ICEQ contains a set of 19 items and 4 components of the intensive care experience: awareness of surroundings (5 items), frightening experiences (6 items), recall of experience (4 items), and satisfaction with care (4 items). Lower scores from the awareness of surroundings subscale indicate a lack of awareness of surroundings during hospitalization, whereas higher scores suggest a high awareness of the surroundings. Similarly, lower scores from the recall of experience subscale show that the subject is not able to remember ICU experiences, whereas higher scores indicate that they recall these experiences. Lower scores from the frightening experiences subscale indicate that subjects have no frightening experiences during hospitalization at the ICU, whereas higher scores point out to intense frightening experiences. Lower scores from the satisfaction with care subscale are not satisfied with the care at the ICU, whereas higher scores demonstrate satisfaction with the care they receive. Part 3. The Relationship Scales Questionnaire (RSQ) was used to determine patients' attachment style. It has been developed by Griffin and Bartholomew [41]. Validity and reliability of RSQ's Turkish version have been established by Sumer and Gungor [42] in 1999. The Relationship Scales
2.4. Data collection Initially, the patients admitted to the ICU were screened according to the inclusion criteria, and the patients to be included in the study were selected at admission. Data in the structured questionnaire (part 1) were collected, and subjects' APACHE II (part 4) scores were calculated during admission to the ICU. Furthermore, subjects' APACHE II (part 4) scores were calculated and recorded at discharge/ transfer from the ICU. After patients in the study were transferred/discharged to the unit from the ICU, an ICU nurse administered the ICEQ (part 2) and RSQ (part 3) in the
103.e10 Table 1
N. Kaya Demographic and clinical variables (n = 108) n (%)
Sex
Female Male 20-31 32-43 44-55 56-67
54 (50.0) 54 (50.0) Age groups (t) 27 (25.0) 15 (13.9) 35 (32.4) 31 (28.7) Age (y), mean ± SD (range) 45.18 ± 13.66 (minimum, 20; maximum, 65) Type of ICU admission With plan 76 (70.4) Without 32 (29.6) plan Mechanical ventilation status Yes 91 (84.3) No 17 (15.7) Length of mechanical ≤24 74 (68.5) ventilation (h) a N24 17 (15.7) 26.51 ± 56.69 Length of mechanical ventilation (h), (minimum, 1; mean ± SD (range) a maximum, 268) Length of ICU stay (d) ≤10 101 (93.5) N10 7 (6.5) ICU days, mean ± SD (range) 2.86 ± 4.13 (minimum, 1; maximum, 25) Previous intensive care Yes 26 (24.1) experience status No 82 (75.9) APACHE II score, mean ± SD 19.00 ± 7.34 during admission to ICU (range) (minimum, 5; maximum, 43) APACHE II score, mean ± SD 9.91 ± 4.64 (minimum, 2; during discharge from ICU (range) maximum, 26) a
These questions were answered by 91 people who received mechanic ventilation.
unit. Any missing information in the structured questionnaire was also completed during these visits.
2.5. Ethical approval Approval for using ICEQ, RSQ, and APACHE II was received from Rattray, Bartholomew, Sumer, and Knaus. A written approval for the execution of the research was received from the ethics committee of the hospital where the study was conducted. The participants were assured that there were no correct or wrong answers, and they were asked to be as genuine as possible. They were also advised that their responses would be anonymous and that the data were to be used for scientific purposes only.
2.6. Data analysis
using arithmetic average, standard deviation, and minimum and maximum values, whereas nominal data were evaluated using frequency and percentage. The normality analysis of the data collected was carried out by using KolmogorovSmirnov goodness-of-fit test in one group, and data were not normally distributed. Spearman ρ correlation technique was used for determining the relationship between 2 ordinal data. Averages of the 2 groups were compared by Mann-Whitney U test, whereas Kruskal-Wallis test was used to compare the average of more than 2 groups. Bonferroni-adjusted MannWhitney method was used in cases where statistically significant differences were determined. The P value is significant at the .05 level [46].
3. Results 3.1. Participants' demographic and clinical characteristics Demographic and clinical characteristics of participants are presented in Table 1.
3.2. Participants' intensive care experience The mean scores calculated from the patients' awareness of surroundings subscale of ICEQ, the recall of experience subscale, the frightening experiences subscale, and the satisfaction with care subscale were 21.46, 12.10, 15.54, and 13.69, respectively (Table 2).
3.3. Participants' attachment style Table 3 displays the attachment styles of participants according to RSQ. According to the data from this research, the dismissing attachment style had the highest score means, followed by the fearful, preoccupied, and secure attachment styles. On the other side, of the total participants, 30.6% had a fearful attachment style; 28.6%, dismissing; and 20.4%, secure and preoccupied attachment styles.
Table 2 Mean and SD scores for intensive care experience of patient according to ICEQ (n = 108) The ICEQ subscales Awareness of surroundings Recall of experience b Frightening experiences c Satisfaction with care d a b
The data were analyzed using SPSS version 11.0 for Windows (SPSS, Chicago, Ill). Ordinal data were evaluated
c d
Range, 5-25. Range, 4-20. Range, 6-30. Range, 4-20.
Mean ± SD a
21.46 ± 3.43 12.10 ± 3.07 15.54 ± 4.41 13.69 ± 3.15
Attachment styles of individuals discharged from an ICU Table 3 Mean and SD scores for attachment styles of patient according to RSQ a (n = 108) Attachment styles
Mean ± SD
Secure Fearful Preoccupied Dismissing
2.91 ± 0.79 3.22 ± 0.95 3.15 ± 0.60 3.28 ± 0.72
a
Range, 1-5.
3.4. Effects of participants' attachment style on the intensive care experience and health status Table 4 gives the descriptive statistics and results of the nonparametric test of ICEQ subscales scores by attachment styles of the participants. Kruskal-Wallis test showed a significant difference in the awareness of surroundings subscale for attachment styles (P ≤ .01). Effects of participants' attachment styles on the awareness of surroundings subscale scores were examined using Bonferroniadjusted Mann-Whitney test (P value is significant at the .01 level), and they showed statistically significant differences between the secure and fearful groups (Z = −3.055, P = .002) and secure and dismissing groups (Z = −2.539, P = .011). The highest awareness of surroundings subscale score was in the fearful group, followed by dismissing, preoccupied, and secure groups. In addition, the correlation between ICEQ subscales scores and participants' attachment style points was examined. The correlation showed higher fearful attachment style scores with increasing awareness of surroundings subscale scores (r = 0.210, P = .029), indicating a weak positive association between fearful attachment style and the awareness of surroundings scores. Similarly, the correlation between awareness of surroundings subscale scores and participants' dismissing attachment style points revealed higher dismissing scores with increasing awareness of surroundings (r = 0.284, P = .003), indicating a positive association between dismissing attachment style and the awareness of surroundings scores. On the other hand, a significant correlation was noted between preoccupied attachment style and satisfaction with care subscales points (r = 0.255, P = .008). This result pointed out that preoccupied individuals were more satisfied with the care Table 4
103.e11 they had received. The correlation between satisfaction with care subscale scores and participants' dismissing attachment style scores revealed lower dismissing attachment style points with increasing satisfaction with care (r = −0.227, P = .018), indicating a weak negative association between dismissing attachment style and the satisfaction with care scores (Table 5). The correlation between participants' attachment style points and APACHE II score during admission to ICU and during discharge from ICU was examined. A significant correlation was also not determined between participants' attachment style points and APACHE II score during admission to ICU (P N .05). Moreover, participants' insecure attachment style points (fearful, preoccupied, and dismissing) and APACHE II score during discharge from ICU were not significantly correlated (P N .05). On the other hand, a highly significant correlation was observed between participants' secure attachment style points and APACHE II score during discharge from ICU (P b .01; Table 6).
4. Discussion This is the first known study to examine the effect of attachment styles of individuals discharged from an ICU on their ICU experience and health status. Intensive care units are health care settings where a wide range of lifesaving methods of care and treatment are implemented through an interdisciplinary approach. On the other hand, individuals may have several negative experiences during their stay at ICUs, and these experiences seem to be associated with a great variety of factors. A negative intensive care experience may not only influence the quality of care provided but may also result in undesired effects on the individuals' lives even after their discharge from the ICU [9-12].
4.1. Discussion of participants' intensive care experience A review of the scores of the subjects of the present study received from the ICEQ showed that their highest mean score was from the awareness of the environment subscale, whereas their lowest mean score was from the recall of
Affects of patients' attachment styles on intensive care experience (n = 108)
Secure Fearful Preoccupied Dismissing Kruskal-Wallis
n (%)
Awareness of surroundings
Recall of experience
Frightening experiences
Satisfaction with care
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
22 (20.4) 33 (30.6) 22 (20.4) 31 (28.6) test
18.59 ± 5.51 22.52 ± 1.80 21.95 ± 2.17 22.03 ± 2.50 χ2 = 10.820, P = .013
12.23 ± 3.26 11.24 ± 2.82 12.27 ± 2.86 12.81 ± 3.25 χ2 = 5.096, P = .165
15.34 ± 5.55 15.95 ± 3.76 14.59 ± 4.13 15.91 ± 4.43 χ2 = 1.037, P = .792
13.59 ± 3.87 13.42 ± 2.95 15.05 ± 2.75 13.06 ± 2.91 χ2 = 6.259, P = .100
103.e12 Table 5
N. Kaya The relationship between RSQ and ICEQ scores of patients (n = 108)
Secure Fearful Preoccupied Dismissing
Awareness of surroundings (r)
Recall of experience (r)
Frightening experiences (r)
Satisfaction with care (r)
−0.047 0.210 ⁎ 0.144 0.284 ⁎⁎
−0.007 −0.130 −0.034 0.020
−0.168 0.152 −0.019 0.100
0.071 −0.143 0.255 ⁎⁎ −0.227 ⁎
⁎ Correlation is significant at the .05 level (2-tailed). ⁎⁎ Correlation is significant at the .01 level (2-tailed).
(ICU) experience subscale. These data indicate that the subjects of the present study were aware of their environment during their stay at the ICU. Several studies have reported that individuals heard the sounds and alerts of the equipment and the staff at ICUs, reminding of the care and treatments they had received [47]. Therefore, the members of health care teams should take these data in consideration while providing care and treatment to both conscious and unconscious individuals in ICUs. Intensive care patients experience several types of stress related to utter helplessness, cognition, the body, the room, and their relationships with others [10,11,48]. Llenore and Ogle [49] reported that patient care within an ICU can be a difficult and stressful task for even the most experienced and skilled critical care nurse. Good communication between the patient, relatives, and nurse is integral to quality care of the patient and should extend to the entire health care team. Furthermore, attachment styles have been empirically linked to the quality of the patient-provider relationship and treatment adherence [6,25,27,28,31-38,50-52].
4.2. Discussion of participants' attachment style According to Hunter and Maunder [31], attachment theory provides a unique, simple, and pragmatically useful model for understanding the particular ways in which individuals can feel and react when stressed by illness and how the professional may help manage that distress. In their original sample, Bartholomew and Horowitz [1] reported the percentage of participants with secure, fearful/ avoidant, preoccupied, and dismissing attachment styles as
Table 6 The relationship between RSQ and APACHE II scores of patients (n = 108)
Secure Fearful Preoccupied Dismissing
APACHE II score during admission to ICU (r)
APACHE II score during discharge from ICU (r)
0.113 0.149 −0.088 0.058
0.322 ⁎ −0.078 −0.112 −0.127
⁎ Correlation is significant at the .01 level (2-tailed).
47%, 21%, 14%, and 18%, respectively. In most studies involving predominantly adults, the distribution of attachment styles resembles that found in the infant studies. That is, in samples using self-report measures, about 55% to 65% of respondents have been found to be secure; 22% to 30%, avoidant; and 15% to 20%, ambivalent or anxious [25,51]. The distribution of attachment styles among participants in the studies also warrants discussion [53,54]. Compared with many samples, there were relatively fewer securely attached participants in the present sample, although relative rates for the 3 insecure attachment styles were consistent with other studies.
4.3. Discussion on the effects of participants' attachment style on the intensive care experience and health status Some studies have shown that attachment style can affect the disease process. Ciechanowski et al [28] have reported that the number of lifetime medically unexplained symptoms varied significantly as a function of attachment style group, with patients with fearful attachment reporting significantly more medically unexplained symptoms than patients with secure attachment, and the number of lifetime medically unexplained symptoms being positively correlated with continuous ratings of fearful attachment and preoccupied attachment. Tacon [55] assessed women with and without breast cancer in terms of attachment history and early loss, closeness to parents, and adult attachment. Women with breast cancer reported significantly higher incidences of insecure histories and early loss and scored significantly higher on avoidant attachment than women without cancer [55]. The present study showed a weak positive association between fearful-dismissing attachment styles and awareness of surroundings scores. Granja et al [56] reported that 38% of the patients stated that they did not remember any moment of their ICU stay. On the other hand, Granja et al [56] have claimed in this study that neuropsychological consequences of critical illness, in particular, the recollection of ICU experiences, may influence subsequent health-related quality of life. Capuzzo et al [57] demonstrated that delusional memories are the most persistent consequence over time, followed by feeling memories, whereas only some memories
Attachment styles of individuals discharged from an ICU
103.e13
of factual events were stable. The authors also described that the patients without a clear memory of the ICU and the patients with infection reported a greater number of delusional memories than did those with a clear memory of the ICU and those without infection. Hence, patients' awareness of the environment in ICUs is affected by many factors. The present study is the first to investigate patients' awareness of the environment in ICU's with consideration to attachment styles. However, admission of a significant proportion of the patients in this study was planned, which might have influenced their awareness of the environment. The present study showed a weak negative association between dismissing attachment styles and satisfaction with care scores. Meredith et al [34] demonstrated that secure attachment, high levels of comfort with closeness, and low levels of anxiety over relationships were each related to greater perceived concern of others, more support, greater satisfaction with support, and more support-seeking behavior, compared with insecure attachment. The findings of the above study conflict with those of the present study. It was expected that secure attachment style was a positively impact in health status. However, the present study demonstrated that APACHE II scores at discharge increased significantly with higher scores of secure attachment style, indicating a poor overall physiological state. The “felt security” associated with an adequate attachment relationship is deemed to provide a safe environment in which to practice and develop a range of difficult skills, including the regulation of emotions [58]. It is, however, quite difficult to provide a secure environment in an ICU. The finding of the present study may be explained with this situation.
style and health status during discharge from the ICU. The patients in an ICU stay away from their significant other. The securely attached patients may be affected by this situation. Therefore, the family must be allowed to visit, especially the securely attached patients anytime. Although family visit to the ICU increases the workload for nurses, it has a positive effect on the patient and the patient's family. Nurses tried to comfort the family by preparing them for their visit to the unit [59]. Intensive care units in some hospitals connected to the public and private sector are allowed to restrict family visits in Turkey [59]. The result of the present study may benefit the patients by regulating significant other visit time.
5. Conclusion This study's results showed that people with a fearful and dismissing attachment style were more aware of their surroundings than people with a secure attachment style, whereas preoccupied people had more satisfaction with care, and dismissing individuals had less satisfaction with care. According to the attachment theory, ensuring adaptation to the ICU may have several advantages in terms of nursing care, including (a) identifying potential factors that may lead an individual to refuse to participate in care, (b) identifying individuals at the risk of adaptation difficulties to ICU, and (c) planning the care to be given to an individual by taking into consideration his/her attachment style. Caregivers may also be recommended to refer to the theories of Johnson [17] or Roy [18], who addressed individuals' attachment styles in planning and implementing the care of patients in ICUs. On the other hand, problems about attachment styles may be writing to nursing care plan with nursing diagnose “risk for impaired attachment.” It was argued in the present study that there exists a significant positive correlation between secure attachment
6. Limitations This study is the first, to the best of our knowledge, to reveal the effects of participants' attachment style on the intensive care experience and health status. Low correlation scores result from a type I error due to the small sample size for each subgroup. In addition, the data in the present study were gathered at one time point. It is, therefore, not possible to conclude whether intensive care experience and health status are related to attachment styles in all cases. Similarly, it is unclear whether adult attachment style influences adaptation of individuals to an ICU. More rigorous research is needed to answer these important questions.
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103.e14 [12] Strahan EHE, Brown RJ. A qualitative study of the experiences of patients following transfer from intensive care. Intensive Crit Care Nurs 2005;21:160-71. [13] Bowlby J. The making and breaking of affectional bonds: 1. Aetiology and psychopathology in the light of attachment theory. Br J Psychiatry 1977;130:201-10. [14] Holmes J. Social relationships: the nature and function of relational schemas. Eur J Soc Psychol 2000;30:447-95. [15] Kaya N. Attachment styles of nursing students: a cross-sectional and a longitudinal study. Nurse Educ Today 2010;30(7):666-73. [16] Kaya N, Kaya H. Effects of attachment styles of nurses on coping strategies. Turkiye Klinikleri J Med Sci 2009;29(6):1563-72. [17] Johnson DE. The behavioral system model for nursing. In: Riehl JP, Roy C, editors. Conceptual models for nursing practice. New York: Appleton-Century-Crofts; 1980. p. 207-16. [18] Roy C. The Roy adaptation model. In: Riehl JP, Roy C, editors. Conceptual models for nursing practice. New York: AppletonCentury-Crofts; 1980. p. 179-88. [19] Araich M. Roy's adaptation model: demonstration of theory integration into process of care in coronary care unit. ICU Nurs Web J 2001;7:1-12. [20] Brown VM, Dorothy E. Johnson: behavioral system model. In: Marriner-Tomey A, Alligood MR, editors. Nursing theorists and their work. 6th ed. St Louis: The CV Mosby Co; 2006. p. 386-404. [21] Perrett SE. Review of Roy adaptation model–based qualitative research. Nurs Sci Q 2007;20:349-56. [22] Phillips KD. Sister Callista Roy adaptation model. In: Marriner-Tomey A, Alligood MR, editors. Nursing theorists and their work. 6th ed. St. Louis: The CV Mosby Co; 2006. p. 355-85. [23] Tiedeman ME. Roy's adaptation model. In: Fitzpatrick JJ, Whall AL, editors. Conceptual models of nursing. 4th ed. New Jersey: Pearson Prentice Hall; 2005. p. 146-76. [24] Wilkerson SA, Loveland-Cherry CJ. Johnson's behavioral system model. In: Fitzpatrick JJ, Whall AL, editors. Conceptual models of nursing. 4th ed. New Jersey: Pearson Prentice Hall; 2005. p. 83-103. [25] Brennan KA, Shaver PR, Tobey AE. Attachment styles, gender, and parental problem drinking. J Pers Soc Psychol 1991;8:451-66. [26] Burk LR, Burkart BR. Disorganized attachment as a diathesis for sexual deviance: developmental experience and the motivation for sexual offending. Aggress Violent Behav 2003;8:487-511. [27] Ciechanowski PS, Katon WJ, Russo JE, et al. The patient-provider relationship: attachment theory and adherence to treatment in diabetes. Am J Psychiatry 2001;158:29-35. [28] Ciechanowski PS, Walker EA, Katon WJ, et al. Attachment theory: a model for health care utilization and somatization. Psychosom Med 2002;64:660-7. [29] Ciechanowski PS, Russo JE, Katon WJ, et al. Influence of patient attachment style on self-care and outcomes in diabetes. Psychosom Med 2004;66:720-8. [30] Feeney JA. Adult attachment, coping style and health locus of control as predictors of health behavior. Aust J Psychol 1995;47:171-7. [31] Hunter JJ, Maunder RG. Using attachment theory to understand illness behaviour. Gen Hosp Psychiatry 2001;23:177-82. [32] Koopman C, Gore-Felton C, Marouf F, et al. Relationships of perceived stress to coping, attachment and social support among HIVpositive persons. AIDS Care 2000;12:663-72. [33] Maunder RG, Lancee WJ, Nolan RP, et al. The relationship of attachment insecurity to subjective stress and autonomic function during standardized acute stress in healthy adults. J Psychosom Res 2006;60:283-90. [34] Meredith P, Ownsworth T, Strong J. A review of the evidence linking adult attachment theory and chronic pain: presenting a conceptual model. Clin Psychol Rev 2008;28:407-29. [35] Pielage S, Gerlsma C, Schaap C. Insecure attachment as a risk factor for psychopathology: the role of stressful events. Clin Psychol Psychother 2000;7:296-302.
N. Kaya [36] Salmon P, Phil D, Wissow L. Doctors' attachment style and their inclination to propose somatic interventions for medically unexplained symptoms. Gen Hosp Psychiatry 2008;30:104-11. [37] Schmidt S, Nachtigall C, Wuethrich-Martone O, et al. Attachment and coping with chronic disease. J Psychosom Res 2002;53:763-73. [38] Strodl E, Noller P. The relationship of adult attachment dimension to depression and agoraphobia. Pers Relatsh 2003;10:171-85. [39] Demir Y, Korhan EA, Eşer İ, et al. Reliability and validity study of the intensive care experience scale. Turkiye Klinikleri J Nurs Sci 2009;1(1):1-11. [40] Rattray J, Johnston M, Wildsmith JAW. The intensive care experience: development of the ICE questionnaire. J Adv Nurs 2004;47(1):64-73. [41] Griffin D, Bartholomew K. Models of the self and other: fundamental dimensions underlying measures of adult attachment. J Pers Soc Psychol 1994;67(3):430-45. [42] Sumer N, Gungor D. Psychometric evaluation of adult attachment measures on Turkish samples and a cross-cultural comparison. Turkish Journal of Psychology 1999;14(43):71-106. [43] Knaus WA, Draper EA, Wagner DP, et al. APACHE II: a severity of disease classification system. Crit Care Med 1985;13:818-29. [44] Knaus WA, Zimmerman JE, Wagner DP, et al. APACHE—Acute Physiology and Chronic Health Evaluation: a physiologically based classification system. Crit Care Med 1981;9:591-7. [45] Man SY, Chan KM, Wong FY, et al. Evaluation of the performance of a modified Acute Physiology and Chronic Health Evaluation (APACHE II) scoring system for critically ill patients in emergency departments in Hong Kong. Resuscitation 2007;74:259-65. [46] Akgül A. Design of research. Statical analyses techniques in medical researches. “SPSS Applications”. 2nd ed. Ankara: Emek Ofset Ltd. Şti; 2003. [47] Wang K, Zhang B, Li C, Wang C. Qualitative analysis of patients' intensive care experience during mechanical ventilation. J Clin Nurs 2008;18:183-90. [48] Sheen L, Oates J. A phenomenological study of medically induced unconsciousness in incisive care. Aust Crit Care 2005;18(1):25-32. [49] Llenore E, Ogle KR. Nurse-patient communication in the intensive care unit: a review of the literature. Aust Crit Care 1999;12(4): 142-5. [50] Ecke YV. Attachment style and dysfunctional career thoughts: how attachment style can affect the career counseling process. Career Dev Q 2007;55:339-50. [51] Gillath O, Shaver PR, Mıkulıncer M, et al. Attachment, caregiving, and volunteering: Placing volunteerism in an attachment-theoretical framework. Pers Relatsh 2005;12:425-46. [52] Taylor RE, Mann AH, White NJ, et al. Attachment style in patients with unexplained physical complaints. Psychol Med 2000;30:931-41. [53] Magai C, Hunziker J, Mesias W, et al. Adult attachment styles and emotional biases. Int J Behav Dev 2000;24:301-9. [54] Magai C, Cohen C, Milburn N, et al. Attachment styles in 0lder European American and African American adults. Journal of Gerontology: Social Sciences 2001;56B(1):28-35. [55] Tacon A. Attachment experiences in women with breast cancer. Fam Community Health 2003;26:147-56. [56] Granja C, Lopes A, Moreira S, et al, the JMIP Study Group. Patients' recollections of experiences in the intensive care unit may affect their quality of life. Crit Care 2005;9:R96-R109, doi:10.1186/cc3026. [57] Capuzzo M, Valpondi V, Cingolani E, et al. Application of the Italian version of the intensive care unit memory tool in the clinical setting. Crit Care 2004;8:R48-55. [58] Simpson JA, Rholes WS. Stress and secure base relationships in adulthood. Adv Pers Relatsh 1994;5:181-204. [59] Taşdemir N, Özşaker E. Yoğun bakım ünitesinde ziyaret uygulaması: ziyaretin hasta, hasta ailesi ve hemşire üzerine etkileri (Visiting practices in intensive care units: effects of visiting to patients, patient's families and nurses). CÜHemşirelik Yüksekokulu Dergisi 2007;11(1): 27-31.
Effect of attachment styles of individuals discharged from an intensive care unit on intensive care experience Nurten Kaya PhD, BSN Department of Fundamentals of Nursing, Istanbul University Nursing Faculty, Sisli/Istanbul, TURKEY 34381
Keywords: Attachment theory; Intensive care experience; Health status
Abstract Introduction: The present study was conducted as a cross-sectional type to examine the effect of attachment styles of individuals discharged from an intensive care unit (ICU) on intensive care experience and health status. Methods: The population of the study included patients discharged from the ICU in a university hospital. The sample included 108 patients who were selected via simple random sampling method. Data were collected using a Demographic Information Questionnaire, Intensive Care Experience Questionnaire, the Relationship Scales Questionnaire, and Acute Physiology and Chronic Health Evaluation II system. In the analysis of data, frequency, percentage, mean, standard deviation, minimum and maximum values, and Mann-Whitney U, Kruskal-Wallis, Bonferroni-adjusted Mann-Whitney, and Spearman ρ correlation tests were used. Results: A significant difference in the awareness of surroundings subscale for attachment styles was noted (χ2 = 10.820, P ≤ .01). Moreover, participants' attachment styles (fearful, preoccupied, and dismissing) and intensive care experience were significantly correlated. A significant correlation was found between participants' secure attachment style points and Acute Physiology and Chronic Health Evaluation II score during discharge from the ICU (r = 0.322, P = .001). Conclusion: Individuals' attachment styles should be taken into consideration when planning and implementing the nursing care and treatment of individuals hospitalized in an ICU. © 2012 Elsevier Inc. All rights reserved.
1. Introduction Attachment has been defined as an emotional bond between 2 individuals based on the expectation that one or both members of the pair will provide care and protection in times of need [1-4]. Attachment styles are influential on the behaviors of the individuals who are in relationships with one another and also influential in obtaining satisfaction from their relationships, in the level with which the individuals are affected by the problems experienced in E-mail address: [email protected]. 0883-9441/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jcrc.2011.05.020
relationships, and in coping with these problems [1,5-8]. This study was conducted to determine the effect of attachment styles of individuals discharged from an intensive care unit (ICU) on intensive care experience and health status.
1.1. The intensive care experience Experiences of critically ill patients are an important aspect of the quality of care in an ICU [9]. They can be perceived as stressful, particularly when a person is removed from the safety of his/her home and sent to an ICU, an
103.e8 environment that can be experienced as unfamiliar, strange, and frightening [10,11]. Strahan and Brown [12] described the stressors that threaten the patient in the ICU. These include (a) physical response: disturbances of sleep, thirst, pain, and weakness; (b) environmental stressors: inability to distinguish day from night and feeling of being trapped and tied down by equipment; (c) emotional disturbances: impaired cognitive functioning, worries, anxieties, and fear; and (d) communication difficulties: inability to talk when receiving mechanical ventilation [12]. Adult attachment style, as a personal trait, has gained popularity over the past years, and it is believed that it may influence individuals' intensive care experiences.
1.2. Adult attachment theory Originally formulated by John Bowlby [2-4], attachment theory postulates that an attachment system has evolved with birth to ensure an infant's proximity to a caring and protective caregiver. Bowlby [13] defined attachment as “the propensity of human beings to make strong affectional bonds to particular others.” Main [6] has suggested that early attachment behaviors, such as crying and smiling, were innate, whereas later attachment behaviors reflect organized and conditioned strategies for maintaining closeness and security with the attachment figure. Bartholomew and Horowitz [1] have advanced a 4-category model of adult attachment (secure, fearful, preoccupied, and dismissing) that correspond to Bowlby's original working models of the self and others. According to Bartholomew and Horowitz [1], secure individuals (who have positive models of both self and others) are hypothesized to experience a general comfort with closeness and trust in others, and fearful individuals (who have negative models of both self and others) are hypothesized to avoid close relationships because they fear rejection. Preoccupied individuals (who have a negative self model but a positive model of others) are hypothesized to have an intense desire for emotional intimacy coupled with a heightened concern about being rejected, whereas dismissing individuals (who have a positive model of self but a negative model of others) are hypothesized to stress the importance of independence and self-reliance over close relationships [5,8,14]. Attachment styles, which develop during infancy and childhood, may change over time. They may be influenced by some factors such as psychological, sociocultural, and environmental [15,16] and may be involved in several circumstances including the way an individual responds to treatment and how he/she adapts to new environments.
1.3. Clinical and the intensive care experience relevance of adult attachment theory Attachment has also been discussed by Johnson [17] and Roy [18] in nursing theories. Johnson [17] and Roy [18]
N. Kaya claim that attachment styles should be taken into consideration when assessing a patient's behavior and when planning, implementing, and evaluating the provided care [19-24]. Moreover, some studies in the literature adduce that attachment styles are linked to a number of clinically relevant phenomena. These include quality of intimate relationships, depression, postnatal depression, self-esteem, anger and hostility, communication and marital satisfaction, career choice and satisfaction, eating disorders, psychosis, borderline personality disorder, and sexual and health behaviors [6,7,25-39]. This body of literature suggests a potential effect of attachment styles on adaptation to the environment and the health status. Based on this insight, attachment styles of individuals hospitalized in ICUs seem to be a potentially key factor affecting their adaptation to the unit and/or their health status. Therefore, the hypothesis of the study was established as “There are associations between attachment styles and intensive care experiences and health status.” If such a correlation exists, a care and treatment planned by taking into consideration specific attachment styles of individuals would contribute to a swift and uncomplicated health status.
2. Materials and methods 2.1. Purpose and research questions This research was carried out with a cross-sectional design to determine the effect of attachment styles of individuals discharged from an ICU on their ICU experience and health status. Research questions were as follows: • What are the attachment styles of individuals discharged from an ICU? • What are the ICU experiences of individuals discharged from that unit? • Do the attachment styles of individuals discharged from the ICU influence their intensive care experiences and health status?
2.2. Participants and setting The population of the research composed of individuals discharged from the ICU of a university hospital. The number of subjects to be included in the sample was calculated by taking into account the 2008 data of the ICU: 1074 patients had been admitted to this unit in 2008, and 882 of these patients were either discharged or transferred to other health care facilities. The sample size was calculated using the “sample size estimation with a known population” method. The number of individuals forming the sample population was taken as 882. In addition, based on the data from a study by Demir et al [39], a standard deviation of 13.93 was used for Intensive Care Experience Questionnaire
Attachment styles of individuals discharged from an ICU
103.e9
(ICEQ). Accordingly, the results of a study conducted with a 98-person sample group would reflect a 0.02 error rate and 0.95 confidence interval. A total of 108 subjects were included in the study; considering a possible decrease in the number of participants during the study, for example, because of death or withdrawal, 10 additional subjects were also included as reserve. The sample was planned according to simple random sampling method, using the inclusion criteria listed below:
Questionnaire uses 17 items to create continuous subscales of attachment style categories. The RSQ items consists of 5point Likert scales that measure the extent to which each item statement represents the respondent's feelings about close personal relationships. Four attachment style domains corresponding to the relationship style domains include the following: secure, fearful, preoccupied, and dismissing. The continuous scores, which reflect the 4 attachment styles, are obtained by adding the questions that are aiming to measure these styles and by dividing this total by the number of questions in each of the subscales. Thus, the scores from the subscales may range between 1 and 5. Continuous scores that are achieved by using this method are also used for grouping the participants by attachment styles. Each participant in the course of grouping is appointed to the attachment category in which he/she had the highest score. Part 4. The Acute Physiology and Chronic Health Evaluation II is a severity of disease classification system [43], one of the several ICU scoring systems. The original APACHE developed by Knaus et al [44] in 1981 showed a positive correlation with hospital mortality and length of hospital stay in an ICU. It used the worst record of 34 physiological parameters measured in the first 24 hours after hospital admission, with class allocation of patients to broad categories of illness severity based on simple criteria for the evaluation of chronic ill health. A refined version, APACHE II, was introduced in 1985, which was used as an ICU admission score [43]. These were then reduced to 12 routine physiologic measurements (APACHE II). Up to 4 points are assigned to each physiological variable according to its most abnormal value during the first 24 hours in intensive care. Points are also assigned for age, history of severe clinical conditions, and surgical status. The total number of points gives a score ranging from 0 to 71, with an increasing score representing a greater severity of illness. Studies showed that the APACHE II scoring system is not only useful in predicting mortality and length of hospital stay in critically ill patients but is also helpful in monitoring treatment progress, comparing therapeutic efficacy, deciding treatment withdrawal, and comparing performance in different centers [45]. Therefore, APACHE II was used in the present study to examine the associations between attachment style and health status.
- Ages 20 to 65 years - Hospitalization in the ICU for a minimum of 24 hours - Being free from any communication problems and sensory defects - Voluntary decision to participate in the study
2.3. Instruments A questionnaire made up of 4 parts was used in the study: Part 1. A structured questionnaire for examining patients' demographic details (sex, age, marital, educational, and economic status) and clinical variables (type of ICU admission, mechanic ventilation status, length of ICU stay, previous intensive care experience history, and Acute Physiology and Chronic Health Evaluation II [APACHE II] score during admission to ICU and at the time of discharge from ICU) were used. The questionnaire was developed by the researcher in light of the literature. Part 2. Turkish version of ICEQ was used to determine patients' intensive care experiences. The ICEQ has been developed by Rattray et al [40] to evaluate the experiences of patients staying in ICUs. Reliability and validity of the Turkish version of ICEQ were established by Demir et al. [39]. The Turkish form of ICEQ contains a set of 19 items and 4 components of the intensive care experience: awareness of surroundings (5 items), frightening experiences (6 items), recall of experience (4 items), and satisfaction with care (4 items). Lower scores from the awareness of surroundings subscale indicate a lack of awareness of surroundings during hospitalization, whereas higher scores suggest a high awareness of the surroundings. Similarly, lower scores from the recall of experience subscale show that the subject is not able to remember ICU experiences, whereas higher scores indicate that they recall these experiences. Lower scores from the frightening experiences subscale indicate that subjects have no frightening experiences during hospitalization at the ICU, whereas higher scores point out to intense frightening experiences. Lower scores from the satisfaction with care subscale are not satisfied with the care at the ICU, whereas higher scores demonstrate satisfaction with the care they receive. Part 3. The Relationship Scales Questionnaire (RSQ) was used to determine patients' attachment style. It has been developed by Griffin and Bartholomew [41]. Validity and reliability of RSQ's Turkish version have been established by Sumer and Gungor [42] in 1999. The Relationship Scales
2.4. Data collection Initially, the patients admitted to the ICU were screened according to the inclusion criteria, and the patients to be included in the study were selected at admission. Data in the structured questionnaire (part 1) were collected, and subjects' APACHE II (part 4) scores were calculated during admission to the ICU. Furthermore, subjects' APACHE II (part 4) scores were calculated and recorded at discharge/ transfer from the ICU. After patients in the study were transferred/discharged to the unit from the ICU, an ICU nurse administered the ICEQ (part 2) and RSQ (part 3) in the
103.e10 Table 1
N. Kaya Demographic and clinical variables (n = 108) n (%)
Sex
Female Male 20-31 32-43 44-55 56-67
54 (50.0) 54 (50.0) Age groups (t) 27 (25.0) 15 (13.9) 35 (32.4) 31 (28.7) Age (y), mean ± SD (range) 45.18 ± 13.66 (minimum, 20; maximum, 65) Type of ICU admission With plan 76 (70.4) Without 32 (29.6) plan Mechanical ventilation status Yes 91 (84.3) No 17 (15.7) Length of mechanical ≤24 74 (68.5) ventilation (h) a N24 17 (15.7) 26.51 ± 56.69 Length of mechanical ventilation (h), (minimum, 1; mean ± SD (range) a maximum, 268) Length of ICU stay (d) ≤10 101 (93.5) N10 7 (6.5) ICU days, mean ± SD (range) 2.86 ± 4.13 (minimum, 1; maximum, 25) Previous intensive care Yes 26 (24.1) experience status No 82 (75.9) APACHE II score, mean ± SD 19.00 ± 7.34 during admission to ICU (range) (minimum, 5; maximum, 43) APACHE II score, mean ± SD 9.91 ± 4.64 (minimum, 2; during discharge from ICU (range) maximum, 26) a
These questions were answered by 91 people who received mechanic ventilation.
unit. Any missing information in the structured questionnaire was also completed during these visits.
2.5. Ethical approval Approval for using ICEQ, RSQ, and APACHE II was received from Rattray, Bartholomew, Sumer, and Knaus. A written approval for the execution of the research was received from the ethics committee of the hospital where the study was conducted. The participants were assured that there were no correct or wrong answers, and they were asked to be as genuine as possible. They were also advised that their responses would be anonymous and that the data were to be used for scientific purposes only.
2.6. Data analysis
using arithmetic average, standard deviation, and minimum and maximum values, whereas nominal data were evaluated using frequency and percentage. The normality analysis of the data collected was carried out by using KolmogorovSmirnov goodness-of-fit test in one group, and data were not normally distributed. Spearman ρ correlation technique was used for determining the relationship between 2 ordinal data. Averages of the 2 groups were compared by Mann-Whitney U test, whereas Kruskal-Wallis test was used to compare the average of more than 2 groups. Bonferroni-adjusted MannWhitney method was used in cases where statistically significant differences were determined. The P value is significant at the .05 level [46].
3. Results 3.1. Participants' demographic and clinical characteristics Demographic and clinical characteristics of participants are presented in Table 1.
3.2. Participants' intensive care experience The mean scores calculated from the patients' awareness of surroundings subscale of ICEQ, the recall of experience subscale, the frightening experiences subscale, and the satisfaction with care subscale were 21.46, 12.10, 15.54, and 13.69, respectively (Table 2).
3.3. Participants' attachment style Table 3 displays the attachment styles of participants according to RSQ. According to the data from this research, the dismissing attachment style had the highest score means, followed by the fearful, preoccupied, and secure attachment styles. On the other side, of the total participants, 30.6% had a fearful attachment style; 28.6%, dismissing; and 20.4%, secure and preoccupied attachment styles.
Table 2 Mean and SD scores for intensive care experience of patient according to ICEQ (n = 108) The ICEQ subscales Awareness of surroundings Recall of experience b Frightening experiences c Satisfaction with care d a b
The data were analyzed using SPSS version 11.0 for Windows (SPSS, Chicago, Ill). Ordinal data were evaluated
c d
Range, 5-25. Range, 4-20. Range, 6-30. Range, 4-20.
Mean ± SD a
21.46 ± 3.43 12.10 ± 3.07 15.54 ± 4.41 13.69 ± 3.15
Attachment styles of individuals discharged from an ICU Table 3 Mean and SD scores for attachment styles of patient according to RSQ a (n = 108) Attachment styles
Mean ± SD
Secure Fearful Preoccupied Dismissing
2.91 ± 0.79 3.22 ± 0.95 3.15 ± 0.60 3.28 ± 0.72
a
Range, 1-5.
3.4. Effects of participants' attachment style on the intensive care experience and health status Table 4 gives the descriptive statistics and results of the nonparametric test of ICEQ subscales scores by attachment styles of the participants. Kruskal-Wallis test showed a significant difference in the awareness of surroundings subscale for attachment styles (P ≤ .01). Effects of participants' attachment styles on the awareness of surroundings subscale scores were examined using Bonferroniadjusted Mann-Whitney test (P value is significant at the .01 level), and they showed statistically significant differences between the secure and fearful groups (Z = −3.055, P = .002) and secure and dismissing groups (Z = −2.539, P = .011). The highest awareness of surroundings subscale score was in the fearful group, followed by dismissing, preoccupied, and secure groups. In addition, the correlation between ICEQ subscales scores and participants' attachment style points was examined. The correlation showed higher fearful attachment style scores with increasing awareness of surroundings subscale scores (r = 0.210, P = .029), indicating a weak positive association between fearful attachment style and the awareness of surroundings scores. Similarly, the correlation between awareness of surroundings subscale scores and participants' dismissing attachment style points revealed higher dismissing scores with increasing awareness of surroundings (r = 0.284, P = .003), indicating a positive association between dismissing attachment style and the awareness of surroundings scores. On the other hand, a significant correlation was noted between preoccupied attachment style and satisfaction with care subscales points (r = 0.255, P = .008). This result pointed out that preoccupied individuals were more satisfied with the care Table 4
103.e11 they had received. The correlation between satisfaction with care subscale scores and participants' dismissing attachment style scores revealed lower dismissing attachment style points with increasing satisfaction with care (r = −0.227, P = .018), indicating a weak negative association between dismissing attachment style and the satisfaction with care scores (Table 5). The correlation between participants' attachment style points and APACHE II score during admission to ICU and during discharge from ICU was examined. A significant correlation was also not determined between participants' attachment style points and APACHE II score during admission to ICU (P N .05). Moreover, participants' insecure attachment style points (fearful, preoccupied, and dismissing) and APACHE II score during discharge from ICU were not significantly correlated (P N .05). On the other hand, a highly significant correlation was observed between participants' secure attachment style points and APACHE II score during discharge from ICU (P b .01; Table 6).
4. Discussion This is the first known study to examine the effect of attachment styles of individuals discharged from an ICU on their ICU experience and health status. Intensive care units are health care settings where a wide range of lifesaving methods of care and treatment are implemented through an interdisciplinary approach. On the other hand, individuals may have several negative experiences during their stay at ICUs, and these experiences seem to be associated with a great variety of factors. A negative intensive care experience may not only influence the quality of care provided but may also result in undesired effects on the individuals' lives even after their discharge from the ICU [9-12].
4.1. Discussion of participants' intensive care experience A review of the scores of the subjects of the present study received from the ICEQ showed that their highest mean score was from the awareness of the environment subscale, whereas their lowest mean score was from the recall of
Affects of patients' attachment styles on intensive care experience (n = 108)
Secure Fearful Preoccupied Dismissing Kruskal-Wallis
n (%)
Awareness of surroundings
Recall of experience
Frightening experiences
Satisfaction with care
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
22 (20.4) 33 (30.6) 22 (20.4) 31 (28.6) test
18.59 ± 5.51 22.52 ± 1.80 21.95 ± 2.17 22.03 ± 2.50 χ2 = 10.820, P = .013
12.23 ± 3.26 11.24 ± 2.82 12.27 ± 2.86 12.81 ± 3.25 χ2 = 5.096, P = .165
15.34 ± 5.55 15.95 ± 3.76 14.59 ± 4.13 15.91 ± 4.43 χ2 = 1.037, P = .792
13.59 ± 3.87 13.42 ± 2.95 15.05 ± 2.75 13.06 ± 2.91 χ2 = 6.259, P = .100
103.e12 Table 5
N. Kaya The relationship between RSQ and ICEQ scores of patients (n = 108)
Secure Fearful Preoccupied Dismissing
Awareness of surroundings (r)
Recall of experience (r)
Frightening experiences (r)
Satisfaction with care (r)
−0.047 0.210 ⁎ 0.144 0.284 ⁎⁎
−0.007 −0.130 −0.034 0.020
−0.168 0.152 −0.019 0.100
0.071 −0.143 0.255 ⁎⁎ −0.227 ⁎
⁎ Correlation is significant at the .05 level (2-tailed). ⁎⁎ Correlation is significant at the .01 level (2-tailed).
(ICU) experience subscale. These data indicate that the subjects of the present study were aware of their environment during their stay at the ICU. Several studies have reported that individuals heard the sounds and alerts of the equipment and the staff at ICUs, reminding of the care and treatments they had received [47]. Therefore, the members of health care teams should take these data in consideration while providing care and treatment to both conscious and unconscious individuals in ICUs. Intensive care patients experience several types of stress related to utter helplessness, cognition, the body, the room, and their relationships with others [10,11,48]. Llenore and Ogle [49] reported that patient care within an ICU can be a difficult and stressful task for even the most experienced and skilled critical care nurse. Good communication between the patient, relatives, and nurse is integral to quality care of the patient and should extend to the entire health care team. Furthermore, attachment styles have been empirically linked to the quality of the patient-provider relationship and treatment adherence [6,25,27,28,31-38,50-52].
4.2. Discussion of participants' attachment style According to Hunter and Maunder [31], attachment theory provides a unique, simple, and pragmatically useful model for understanding the particular ways in which individuals can feel and react when stressed by illness and how the professional may help manage that distress. In their original sample, Bartholomew and Horowitz [1] reported the percentage of participants with secure, fearful/ avoidant, preoccupied, and dismissing attachment styles as
Table 6 The relationship between RSQ and APACHE II scores of patients (n = 108)
Secure Fearful Preoccupied Dismissing
APACHE II score during admission to ICU (r)
APACHE II score during discharge from ICU (r)
0.113 0.149 −0.088 0.058
0.322 ⁎ −0.078 −0.112 −0.127
⁎ Correlation is significant at the .01 level (2-tailed).
47%, 21%, 14%, and 18%, respectively. In most studies involving predominantly adults, the distribution of attachment styles resembles that found in the infant studies. That is, in samples using self-report measures, about 55% to 65% of respondents have been found to be secure; 22% to 30%, avoidant; and 15% to 20%, ambivalent or anxious [25,51]. The distribution of attachment styles among participants in the studies also warrants discussion [53,54]. Compared with many samples, there were relatively fewer securely attached participants in the present sample, although relative rates for the 3 insecure attachment styles were consistent with other studies.
4.3. Discussion on the effects of participants' attachment style on the intensive care experience and health status Some studies have shown that attachment style can affect the disease process. Ciechanowski et al [28] have reported that the number of lifetime medically unexplained symptoms varied significantly as a function of attachment style group, with patients with fearful attachment reporting significantly more medically unexplained symptoms than patients with secure attachment, and the number of lifetime medically unexplained symptoms being positively correlated with continuous ratings of fearful attachment and preoccupied attachment. Tacon [55] assessed women with and without breast cancer in terms of attachment history and early loss, closeness to parents, and adult attachment. Women with breast cancer reported significantly higher incidences of insecure histories and early loss and scored significantly higher on avoidant attachment than women without cancer [55]. The present study showed a weak positive association between fearful-dismissing attachment styles and awareness of surroundings scores. Granja et al [56] reported that 38% of the patients stated that they did not remember any moment of their ICU stay. On the other hand, Granja et al [56] have claimed in this study that neuropsychological consequences of critical illness, in particular, the recollection of ICU experiences, may influence subsequent health-related quality of life. Capuzzo et al [57] demonstrated that delusional memories are the most persistent consequence over time, followed by feeling memories, whereas only some memories
Attachment styles of individuals discharged from an ICU
103.e13
of factual events were stable. The authors also described that the patients without a clear memory of the ICU and the patients with infection reported a greater number of delusional memories than did those with a clear memory of the ICU and those without infection. Hence, patients' awareness of the environment in ICUs is affected by many factors. The present study is the first to investigate patients' awareness of the environment in ICU's with consideration to attachment styles. However, admission of a significant proportion of the patients in this study was planned, which might have influenced their awareness of the environment. The present study showed a weak negative association between dismissing attachment styles and satisfaction with care scores. Meredith et al [34] demonstrated that secure attachment, high levels of comfort with closeness, and low levels of anxiety over relationships were each related to greater perceived concern of others, more support, greater satisfaction with support, and more support-seeking behavior, compared with insecure attachment. The findings of the above study conflict with those of the present study. It was expected that secure attachment style was a positively impact in health status. However, the present study demonstrated that APACHE II scores at discharge increased significantly with higher scores of secure attachment style, indicating a poor overall physiological state. The “felt security” associated with an adequate attachment relationship is deemed to provide a safe environment in which to practice and develop a range of difficult skills, including the regulation of emotions [58]. It is, however, quite difficult to provide a secure environment in an ICU. The finding of the present study may be explained with this situation.
style and health status during discharge from the ICU. The patients in an ICU stay away from their significant other. The securely attached patients may be affected by this situation. Therefore, the family must be allowed to visit, especially the securely attached patients anytime. Although family visit to the ICU increases the workload for nurses, it has a positive effect on the patient and the patient's family. Nurses tried to comfort the family by preparing them for their visit to the unit [59]. Intensive care units in some hospitals connected to the public and private sector are allowed to restrict family visits in Turkey [59]. The result of the present study may benefit the patients by regulating significant other visit time.
5. Conclusion This study's results showed that people with a fearful and dismissing attachment style were more aware of their surroundings than people with a secure attachment style, whereas preoccupied people had more satisfaction with care, and dismissing individuals had less satisfaction with care. According to the attachment theory, ensuring adaptation to the ICU may have several advantages in terms of nursing care, including (a) identifying potential factors that may lead an individual to refuse to participate in care, (b) identifying individuals at the risk of adaptation difficulties to ICU, and (c) planning the care to be given to an individual by taking into consideration his/her attachment style. Caregivers may also be recommended to refer to the theories of Johnson [17] or Roy [18], who addressed individuals' attachment styles in planning and implementing the care of patients in ICUs. On the other hand, problems about attachment styles may be writing to nursing care plan with nursing diagnose “risk for impaired attachment.” It was argued in the present study that there exists a significant positive correlation between secure attachment
6. Limitations This study is the first, to the best of our knowledge, to reveal the effects of participants' attachment style on the intensive care experience and health status. Low correlation scores result from a type I error due to the small sample size for each subgroup. In addition, the data in the present study were gathered at one time point. It is, therefore, not possible to conclude whether intensive care experience and health status are related to attachment styles in all cases. Similarly, it is unclear whether adult attachment style influences adaptation of individuals to an ICU. More rigorous research is needed to answer these important questions.
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