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Living the situation stress-experiences among intensive care patients
Intensive and Critical Care Nursing (2007) 23, 124—131
REVIEW
Living the situation stress-experiences among intensive care patients Sven-Tore D. Fredriksen a,∗, Karin C. Ringsberg b a
Harstad University College, Institute of Health and Social Sciences, Havnegata 5, 9480 Harstad, Norway b Nordic School of Public Health, Box 12133, SE-402 42 Gothenburg, Sweden Accepted 15 September 2006
KEYWORDS Hermeneutic; Intensive care nursing; Phenomenology; Stress; Experience
Summary The study is about the types of stress that patients in intensive care units experience. Ten reviewed articles selected from Cinahl and Pubmed between 1994 and 2003 constitute the data. The paper is a literature review, and the data is analysed from the phenomenological—hermeneutical point of view. Stress related to the body, room and relationships is discussed. Experiences of stress that are related to the body include bodily stress reactions, deprivation of control, emotions related to technical equipment, procedures and loss of meaning. Stress related to the room highlights the environment and the situation in which the patient finds him/herself. The ethical relations of professionals and separation of patients from their significant others constitute stress related to relationships. © 2006 Elsevier Ltd. All rights reserved.
Introduction Serious disease or severe trauma often lead to life-threatening conditions. These are far beyond everyday experience. They can be experienced as stressful, particularly when a person is removed from the safety of his/her home and sent to an intensive care unit, an environment which can be experienced as unfamiliar, strange and frightening. In a scientific context, stress is referred to ∗
Corresponding author. Tel.: +47 77 05 83 25; fax: +47 77 05 81 04. E-mail address: [email protected] (S.-T.D. Fredriksen).
and is applicable in the natural sciences, as well as in the hermeneutic scientific tradition (Lazarus, 1993). Research on stress within health science has focused on physiological and psychological factors. Instead of seeing stress as the sum of variables describing conditions in the person or environment, this study explores how intensive care is experienced and interpreted by the patients and what the meaning of the situation might be for them. Stress appears when the patient loses the meaning of the situation (Lazarus and Folkman, 1984; Lazarus and Launier, 1978). Being a victim of trauma or having severe disease is a condition, but it can also be described as an existence, a way to relate to the world (Eriksson,
0964-3397/$ — see front matter © 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.iccn.2006.09.002
Stress experiences among intensive care patients 2002). According to Ricoeur (1988), man is related to an exterior world and an inner world at the same time, which constitutes the lifeworld. Relating to something means being extrovert and introvert at the same time. Living a situation, especially one that threatens one’s life and health, often activates former stressful experiences. Seen from a phenomenological perspective, these experiences remain and are always present in the body giving the body both reflective and physical dimensions (Merleau-Ponty, 1994). The physically reflective body, as it is referred to in this article, will react, experience and embody different elements of the situation in many different ways. People are always in a situation, and each situation provides different sets of experiences (Benner and Wrubel, 2001). Person and situation become one through the experiences the person defines as significant or non-significant. The body assimilates experience through sensations present in the situation as the focus of attention. The body is positioned in the situation. Man exists, acts and reflects as a living body (Heidegger, 1992; Engelsrud, 1990). In a sensuous presence with others, relations with others appear. Relating to others includes reciprocity by being in the world together. In this kind of relationship, the body performs a double function in its relationship to others; being touched and touching, it observes and it is observed (Martinsen, 1993). The physical body links the intensive care patient to the intensive care room and by its experiences it becomes omnipresent in the room (Benner and Wrubel, 2001). For the intensive care patient, this involves being in a room which captures the attention of the physically reflective body. The extent of sensation will determine whether the body can push the experience of diseases aside and thus focus on the world beyond. The body’s alternative is to focus inwards, towards a ‘‘bodily space’’ in which it becomes more aware of itself. The body exists at the same time in two aspects of the lifeworld (Leder, 1990). These two lifeworlds represent two separate sets of levels; one objective level and one phenomenological level. They share the fact that they are both caught up in the attention of the person’s mind. Much research has been associated with intensive care patients’ physiological reactions to stress and from a quantitative approach (Tracy and Ceronsky, 2001; Honkus, 2003; Baxter, 2004). However, it is also important to listen to those who have the lived experience of being a patient in an intensive care ward. The purpose of the present study was to describe the kind of stress patients in intensive care experience in relation to the body, room and relationships.
125
Method This article is a literature review. The Pubmed and Cinahl databases were used and the search covers the period 1994—2003. The search words were ‘‘intensive care patients’’ and ‘‘stress’’. The selection of articles was made in two steps.
Inclusion criteria The articles should: 1. be published in English and in journals with a referee system; 2. refer to adult patients >19 years of age; 3. be review articles; 4. describe the dimension of the lifeworld. Twenty hits were found in Pubmed and 10 in Cinahl.
Exclusion criteria The articles should not refer to: 1. diagnoses; 2. treatment strategies. This excluded 14 articles from Pubmed and 6 from Cinahl. The study thus includes a total of 10 articles, 6 from Pubmed and 4 from Cinahl. For details on the articles included, see Table 1.
Analysis The articles were analysed from a phenomenological—hermeneutical approach (Heidegger, 1992; Merleau-Ponty, 1994; Benner and Wrubel, 2001). This means that the researcher has a kind of dialogue with the texts with the purpose of understanding them (Gadamer, 1979; Lindseth, 1981). In the interpretative process, the researcher uses his/her empirical preconceptions. The two authors of the present study have several years’ experience of working in intensive care units as a nurse and a physiotherapist. The following three key questions were raised in relation to the articles: 1. How is the body experienced during serious disease? 2. How is the room experienced during serious disease? 3. How are relationships experienced during serious disease? The results are discussed under three main headings: physical experiences, experiences of the room and experiences of relationships. The first author had the main responsibility for collecting and analysing the data. The data have been con-
126 Table 1
S.-T.D. Fredriksen, K.C. Ringsberg Overview of the 10 review articles on stress and intensive care unit (ICU) patients included in the study
Reference
Honkus (2003)*
Tracy and Ceronsky (2001)*
Clarke and Harrison (2001)*
Black et al. (1997b)*
Nelson (1997)*
The study’s purpose, results and conclusions, method of analysis and number of articles included Purpose: To explain sleep processes and the importance of sleep for ICU patients and how sleep could be promoted by changes in nursing procedures Result and conclusions: Sleep processes are complicated and these processes are often disrupted among ICU patients by light, noise, unease, pain, medication and nursing procedures. When it comes to respecting a person’s need for sleep, practices need to be changed and education provided for the various groups of professionals who work every day in ICUs. The theme also needs to be addressed at academic conferences Method of analysis and articles included: Qualitative approach, 31 articles Purpose: To initiate a process in which patients and their significant others would experience extra support through improved communication and involvement with health care professionals. The purpose was also to increase their knowledge of stress and crisis management Result and conclusions: By using problem-solving processes, patients, significant others and health professionals experienced improved conditions in the ICU. Positive changes took place in the ICU, expressed by the professionals as an increased knowledge of working with patients and significant others. Furthermore, the professionals also improved their knowledge of communication through positive activities Method of analysis and articles included: Qualitative approach, 13 articles Purpose: To identify specific nursing actions to satisfy children’s need to visit the ICU Result and conclusions: Several actions were considered to be important for increasing the knowledge of child communication about health and illness. Children need to be prepared as well as protected from the sensuous impressions of an ICU. Information material needs to be improved and the waiting room must be adapted to children’s needs Method of analysis and articles included: Qualitative approach, 28 articles Purpose: To validate the term sensoristrain, examine its character and characteristics, clarify and illuminate its dichotomy in view of its elements, identify an operational definition of the term applicable to nursing and science and factors which may have changed the term over an extended period of time Result and conclusions: The term must be understood in its double meaning; as sensing and as a physical condition under severe stress. The term could be given additional content by understanding terms like stress, deprivation, overburdening and equilibrium. Reactions caused by sensoristrain in ICU patients were emotional conditions, sympathetic reflexes and a reduced ability to make decisions Method of analysis and articles included: Qualitative concept analysis, 14 articles Purpose: To discuss how an ethical environment could be created as an essential precondition for specific ethical issues derived from specific situations in ICUs Result and conclusions: The focal point was the relationships between physicians and nurses and how patients and their significant others were involved in clinical decisions. In co-operation, respect, integration and communication are as important among physicians, as they are between the physician, the nurse and the patient. Creating a good ethical working environment would not only serve the patient and his significant others, but it might also help the professionals in intensive care to find their work more meaningful Method of analysis and articles included: Qualitative approach, 27 articles
Stress experiences among intensive care patients
127
Table 1 (Continued) Reference
Soehren (1995)*
Powell (2002)ˆ
Curtis (2002)ˆ
Black et al. (1997a)ˆ
Suominen and Leino-Kilpi (1995)ˆ
* ˆ
Articles from the PUBMED. Articles from the Cinahl.
The study’s purpose, results and conclusions, method of analysis and number of articles included Purpose: To clarify which factors were perceived as stressful among patients undergoing heart surgery in an ICU Result and conclusions: Some main factors were found. Maximum stress was found in the patients’ lack of ability to control their situation and in having lost a spouse or partner. Moderate stress was seen due to nasal or oral intubation. Other stressors that were described were the need for extubation, suction procedures, noise and insomnia Method of analysis and articles included: Quantitative descriptive design (n = 43, 34 male, 9 female), 7 articles Purpose: To study literature in order to identify nursing methods which would provide intensive care patients with long-term well-being after hospital treatment Result and conclusions: The recovery phase for intensive care patients was both complex and dynamic. An holistic approach to post-treatment management is required. Nursing often focused on the diagnosis, but this approach did not solve patient problems. ICU wards should take a more active role towards this group of patients, including formal discharge procedures from hospital Method of analysis and articles included: Qualitative approach, 10 articles Purpose: To discuss parametric measurements and consequences of treatment with mechanical respiratory assistance Result and conclusions: The main goal for intensive care treatment is survival. The diagnosis predisposes many patients to critical illness, including manual respiratory treatment. The condition may also affect the patient’s general quality of life and bodily functions long after intensive treatment. This requires the mapping of treatment and procedures in order better to identify improved and more efficient care. Highlighting these consequences was found to be important from a theoretical and a practical perspective. Post-mechanical ventilation traumas ought to be more thoroughly investigated Method of analysis and articles included: Qualitative approach, 69 articles Purpose: To analyse patient experiences of sensoristrain and nurses’ practical roles in an ICU in the light of Neuman’s theory, with special emphasis on stress in order to clarify and provide guidance for everyday practice Result and conclusions: Neuman’s theory was found to be relevant as a model for examining sensoristrain among intensive care patients. In the current economic climate, advanced nursing should emphasise professional values and articulate the contribution nursing intervention represents — and above all show that nursing involves not only caring for the physical body but also a humanistic effort of which knowledge of the body is an essential part Method of analysis and articles included: Qualitative approach, 40 articles Purpose: To study the scientific papers that appeared in Intensive and Critical Care Nursing (ICCN) in 1985-1991 and to compare this published research with what Finnish staff nurses in ICUs would have liked to prioritise as areas for research Result and conclusions: The main problems for intensive care nurses are coping and developing professional skills and quality of care, while the papers published in the ICCN focus on staff-related research and stress. The 1980s and 1990s focused on patients, while the current need is to focus on stress among staff. Communication skills could provide greater satisfaction among staff. More research on intensive care nursing in Europe is needed Method of analysis and: Qualitative approach, 294 articles
128 tinuously discussed by the two authors. Both have been responsible for writing the article.
Findings The organization of the findings are based at the key question in the article, i.e. stress related to the body, room and relationships. The section also contains reflections, but these are of a more overall level.
Experiences of the body Bodily reactions We and our bodies are always in a situation, according to Benner and Wrubel (2001). Being in a situation, being seriously ill and being a patient in an ICU influences the body, which is described as stressful. When the body is ill, especially seriously ill, physical changes occur. In the articles, patients describe stress reactions like sweating, increased heart frequency, hyperventilation and restlessness. Body in a phenomenological context also includes being a body, not merely having one. By being a body, we exist in and with the body. When an intensive care patient experiences physical reactions from the sympathetic nervous system, the reflective body’s nature will be turned against the experiences of these reactions. The experiences will thus be embodied and ‘‘wake up’’ the person’s attention (Merleau-Ponty, 1994). The body’s ability to recognise former experience, by its embodied knowledge, enables it to ‘‘wake up’’ when similar yet different experiences occur in a new situation. The bodily sensations do not make sense, but the lack of sense creates a stress response (Benner and Wrubel, 2001). Insomnia is another physical phenomenon which is described in the situation. Procedures, care provision and noise around the patients prevent them from sleeping. Sleep has a healing effect on the body through several bodily functions, but sleep is also an expression of the body’s self-regulating nature. When external factors determine the life conditions of the ‘‘private room’’ and the ‘‘physical room’’, the patient’s need for sleep becomes invisible. Man perceives the world around him with his body and its senses. Disturbed sleep forces the senses into action. Sleep itself shuts the senses down and prevents the body from perceiving the world, keeping the world out. Deprivation of control The articles also describe other physical reactions to being deprived of control, including fear and pain. These phenomena are frequently seen
S.-T.D. Fredriksen, K.C. Ringsberg in severely ill patients. Losing control of the situation is often experienced as a threat by the patients. Understanding oneself, in a phenomenological way, means understanding oneself retrospectively. One situation is often linked to former situations and its meaning is often interpreted by earlier experiences. Fear and pain not only express changes and reactions in the body, they are also far-reaching consequences of the effects these phenomena have on the entire self. Phenomena and situations merge and are visible in the individual’s recognition of fear and pain. Recognition provides contact with the body, not only because man lives in a body — but because the body itself lives in man. Stress occurs when the body meets negative recognition. Emotions on technical equipment and procedures Technical equipment and procedures used to sustain vital functions were also experienced as stressful by the ICU patients. It relates, for example, to respirators, intubation and cleaning respiratory tracts. For some patients, mechanical respiration with the assistance of a machine might symbolise security and a promise of life, for others an experience of trauma and fear by being bound to this machinery. Being in the situation may even provoke emotional reactions in patients. Patients also experience a reduced ability to see opportunities or an ability to make decisions, fear of being stuck in a situation, confusion and in some cases hallucinations. Loss of meaning It is often difficult to live a situation in which many factors appear to be without meaning. Meaningfulness helps man to understand a situation and the reason why man exists. The reflected body applies its vocabulary to find meaning and, when it does not do so, stress occurs. When the body and its potential for action experience limitations in functionality, this affects the body’s life, sustainability and future. A severely ill person cannot move his body away from the situation, but, in critical situations, when the situation becomes overwhelming, the mind may provide an escape from the situation by moving out of the body with its thoughts.
Experiences of the room Bodily senses Stress originating from the character of the room is described in the articles. The intensive care unit is a special environment. The situation is created
Stress experiences among intensive care patients by the room the body perceives through its senses and the persons in it. The situation is also affected by the position from which the body senses the room. Lying in a bed gives a different perception of the room than standing upright. Being in the room means embodying the situation and reaching out to the room with one’s body (Merleau-Ponty, 1994). The intensive care room as a room and context carries no meaning in and of itself. However, it is given meaning through social and cultural contexts, being alive yet being critically ill (Gjengedal, 1994). Through the body’s experience of two simultaneous existences, being alive and being seriously ill, the intensive care room reaffirms the existence of life and being in it. The body is able to feel this combined existence through sensuous confirmation. When the situation is impressed by strong light and troublesome noise and when the patient’s significant others are not integrated with the patients, this clearly contrasts to the prerequisites of the patient. Stress occurs when light becomes bothersome from the patient’s perspective in the bed, since horizontal and vertical light sensations are very different. Important sounds become indistinguishable from noise and create a sense of meaninglessness, since a horizontal position also enforces phenomena like power and powerlessness. In this context, power should not be regarded in a traditional paternalistic way, but by the body’s own opportunity to sustain life. The aspect of power can be illustrated by the critically ill body falling victim to its own situation as critically ill. The strain on the body in a situation like this is imposed on it and the body has no way of affecting the outcome of the situation in any particular way. The situation and all its elements take control of the body. Powerlessness is the sum of experiences and the physical limitations of the horizontal position of the body in the room. This position limits the body’s opportunities in terms of its functions, as responsive to the demands and expectations often associated with life preservation.
Experiences of relationships Disturbances in relation Relation-based stress is described in articles linked to situations related to the observation of the patients, care provision and treatment. These often occur simultaneously. Patient observation procedures are often experienced by the patients as more stressful than light or noise. The way care is organised often affects the satisfaction of elementary physical needs in the patient, as well as his/her fear and anxiety. Patients and their significant others rate continuity of care and the proximity of
129 nurses and physicians as very important. Continuity may be disturbed by ethical or professional differences between nurses and physicians. The close relationship is essential in terms of safety as well as hope. Disturbances are often caused by how busy the situation is. An atmosphere of being busy may change the sense of a ‘‘room’’ being filled with hope and safety to a ‘‘room’’ with a lack of care. This affects significant others, the patient and the care provider’s tasks. People are created for each other and thus demand help from each other (Martinsen, 1993). Being critically ill means being dependent on assistance with life-supporting actions a person is unable to perform by him/herself. In this situation, nurses and significant others become the arms and the identity of the patient—–the nurses by acting on behalf of the patient and significant others by knowing the patient’s personality and habits. The lack of feeling significant or deprived of continuous contact and separation from one’s loved ones can be experienced as stress. In one article, significant others refer to similar experiences. The bodies of the patients and their significant others sense each other’s state of mind. In this way also, the relational experiences are made significant. Even if the situation may not be perceived identically, these phenomena are important to people who experience the situation. As a consequence, situational phenomena may be characterised as stress or potential stress induced in both patients and their significant others. Relation and communication are often connected. Different characteristics of the situation’s relational dimension are referred in the articles. Intensive care patients are often unable to express themselves verbally because they are intubated. Words make a person visible to others (Lillestø, 1997). The body is accustomed to expressing itself in words and actions. When words cannot be expressed and the body’s power of movement is limited by critical illness, helplessness may manifest itself by experiencing a lack of meaning and stress.
Discussion Benner and Wrubel (2001) claim that knowledge is embodied. This implies that the body affects the mind, as the mind affects the body. Stress comes from the person’s relationship to the situation and his/her abilities to adapt to it. Ten review articles (see Table 1) were analysed from a phenomenological—hermeneutical angle to determine how stress is experienced by intensive care
130 patients from three different approaches, related to: (1) the body, (2) the room and (3) relationships. The quality of the articles appeared to be different in terms of the description of methodology. In spite of this, all the articles have been judged to be valid. Physical responses in patients described in the articles were perspiration, increased pulse, hyperventilation and restlessness. Leder (1990) applies the term ‘‘disappearing body’’ to describe the condition the body experiences. It is captured in experiences demanding attention. The body’s appearance is dysfunctional, since its senses make it the sole object of attention. When the body considers itself, the body becomes estranged and unrecognisable. The body moves from being attentive in the room outside to focus on its internal room. Such changes to ‘‘being in the world’’ often feel meaningless and induce stress. Stress related to the body also includes insomnia. Being deprived of the body’s rhythmical patterns of activity, rest and sleep, in addition to being seriously ill, is an added strain. The time of sleep and the reduced quality of sleep was described as one of the most serious stress factors. As different to a patient suffering from stroke, the intensive care patient has not lost his/her embodied knowledge. Nor has he/she, as is seen in patients with dementia, lost his/her ability to make use of this knowledge. However, the intensive care patient’s body is not given the opportunity to maintain its strength and reconstitute itself through the provision of regular sleep and rest. Anxiety and pain were also described as other dimensions of stress. These are phenomena beyond their obvious physical effects; they affect the whole being. Pain and anxiety make contact with the body and the body becomes the focus of the attention. Pain and anxiety also affect the structure of the body. Depending on their expressions and intensity, they may — together or separately — constitute a threat to the body’s survival. The articles also described intensive care patients being exposed to mental stress. Heidegger (1992) refers to man’s ‘‘being in the world’’ as a kind of confidence in one’s surroundings and loved ones. This confidence is expressed by pre-reflexive and immediate responses. When the intensive care patient encounters a situation which tunes the body to a specific sensation, for example, when acute/critical illness threatens the being’s survival, stress appears as immediate life utterances like concern, resignation or psychosis. Stress can also appear as a reaction related to the treatment itself, such as when the patient is on life-support machinery. By living in the body, unable physically to remove oneself from the situation, the experience
S.-T.D. Fredriksen, K.C. Ringsberg becomes overwhelming. The search for meaning makes the intentional individual look for potentially new solutions. His/her life utterances are a confirmation of this search. The search for solutions involves numerous stress experiences, that include a loss of understanding and meaning in the situation. According to Merleau-Ponty (1994), the body is not present in the room but lives the room. The intensive care patient perceives the room with his/her body’s senses and can reach out into the room with his/her body’s ability to influence its environment. In such a dynamic, the body’s potentials will be focused in various ways. What the body encounters provides information about the body’s condition when it meets the room. The body thus becomes its own focus of attention. Intensive care patients usually meet the room in a horizontal position. The light is stressful because its appearance to the bedridden patient is not to light up the room but rather to shine in the eyes. Nor will he/she experience light regulating his embodied knowledge of changes between night and day. When unfamiliar and intense sounds reach the body and its mind, their alien character produces stress. The room also changes the person’s relational needs versus significant others. Being cut off from normal relationships means being deprived of opportunities for sharing. Sharing is a natural process in the living world, as well as in the room to which the intensive care patient is confined. This separation from sharing brings out the question of power and lack of control. Power is illustrated by the patient’s constant reminder that he is separated from his loved ones. Lack of control is illustrated by his/her body’s limitations in the room and the experiences such limitations produce. According to Løgstrup (2000), all life revolves around being in or dealing with relationships. Life was created in order to ‘‘receive the other’’. This philosophy emphasises that people are made for each other and to care for one another. In an ICU, life utterances appear in the relationship between staff internally and with the patient in varying degrees of proximity, continuity and predictability. They also appear when there are conflicts among staff or when management or continuity in care fails. Relationships may be strengthened by good professional care and observation of the patient, but also by including the patient’s loved ones, including children. Threats to the relationship may affect the stress condition in the intensive care patient and worsen his/her condition. This stress is particularly complicated, as the patient is often unable to express his/her needs in words when he/she is on life-support machinery.
Stress experiences among intensive care patients
Conclusion and clinical implications This article shows that intensive care patients experience several types of stress related to the body, the room and their relationships with others, experiences that are integrated in the patient as the reflected body. This stress is vitally important to the patient’s experience of body and situation and is often threatening to his/her existence. Being trapped in a condition of stress can affect the ICU patient’s situation dramatically, because of small margins. In a clinical context, this experience-based knowledge is important, since it can be decisive for the patient’s situation. The patients are influenced because what they experience and perceive in the situation is not seen and understood by the professionals since their experienced-based knowledge to a large extent is absent. This leads to a relational discourse which is observing and where the patients with their marginal opportunities are excluded. The patient often experiences this as a dramatization of her situation which in turn may lead to loss of willpower, capability and vitality. The experienced-based knowledge therefore has another status than the observing knowledge precisely because it changes with the constantly perceiving patient. Such a dialectic knowledge might also appear and influence relations by having an effect on the patient—professional relationship. To be able to observe, understand and apply experience-based knowledge where it is needed requires practicing being influenced. The best way of doing so is in situations where knowledge can be gathered. Sensation perceptive knowledge should be encouraged, not only on a practical and professional level, but also within education. More research is needed to describe the different phenomena experienced by the patient in an intensive care context. Research is also required exploring how knowledge is transferred in an educational situation involving the patient.
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131 Black P, Deeny P, McKenna H. Sensoristrain: an exploration of nursing interventions in the context of the Neuman systems theory. Intensive Crit Nurs 1997a;13(Oct (5)):249— 58. Black P, McKenna H, Deeny P. A concept analysis of the sensoristrain experience by intensive care patients. Intensive Crit Nurs 1997b;13(Aug (4)):209—15. Clarke C, Harrison D. The needs of children visiting on adult intensive care units: a review of the literature and recommendations for practice. J Adv Nurs 2001;34(April (1)):61—8. Curtis JR. The long-term outcomes of mechanical ventilation: what are they and how should they be used? Respir Care 2002;47(April (4)):496—507. Engelsrud G. Kroppen -glemt eller anerkjent. In: Jensen K, editor. Moderne omsorgsbilder. Oslo: Gyldendal; 1990. p. 159—78. Eriksson K. Caring science in a new key. Nurs Sci Q 2002;15:61—5. Gadamer HG. Truth and method. London: Sheed and Ward; 1979. Gjengedal E. Understanding a world of critical illness. Department of Public Health and Primary Health Care, Division for Nursing Science, University of Bergen: Bergen; 1994. Heidegger M. Varat och tiden (Sein und Zeit). Gothenburg: Daidalos; 1992. Honkus VL. Sleep deprivation in critical care units. Crit Care Nurs 2003;26(July—September (3)):179—89. Lazarus RS. From psychological stress to the emotions: a history of changing outlooks. Annu Rev Psychol 1993;14:1—21. Lazarus RS, Folkman S. Stress, appraisal, and coping. New York: Springer; 1984. Lazarus RS, Launier R. Stress-related transaction between person and environment. In: Pervin LA, Lewis M, editors. Perspective in interact psychology. New York: Plenum; 1978. p. 287—327. Leder D. The absent body. London: The University of Chicago Press Ltd; 1990. Lillestø B., N˚ ar omsorgen oppleves krenkende Avhandling Dr. polit graden. Institutt for Samfunnsvitenskap, Universitetet i Tromsø. Bodø: Nordlandsforskning; 1997. Lindseth A. Den filosofiske hermeneutikk reflekterer over betingelsene for at forst˚ aelse overhode kan lykkes. Intervju med Hans Georg Gadamer. Dyade 1981;4:29—47. Løgstrup KE. Den etiske fordring (The ethical demand). Oslo: Cappelen; 2000. Merleau-Ponty M. Kroppens fenomenologi (Ph` enom` enologie de la perception). Oslo: Pax Forlag; 1994. Martinsen K. Fra Marx til Løgstrup. Om etikk og sanselighet i sykepleien. Oslo: Tano; 1993. Nelson RM. Ethics in the intensive care unit. Creating an ethical environment. Crit Care Nurs 1997;13(Jul (3)):691—701. Powell J. Caring for patients after an ICU admission. New Zealand: Kai Tiaki Nursing 2002;8(Aug (7)):24—5. Ricoeur P. Fr˚ an text till handling. In: 1992 Lund Symposium; 1988 (Mangler denne I reflista). Soehren P. Stressors perceived by cardiac surgical ptients in the intensive care unit. Am J Crit Care 1995;4(Jan (1)):71—6. Suominen T, Leino-Kilpi H. There is very little European research on intensive care nursing. Intensive Crit Care Nurs 1995;11:244—51. Tracy MF, Ceronsky C. Creating a collaborative environment to care for complex patients and families. AACN Clin Issues 2001;12(Aug (3)):383—400.
REVIEW
Living the situation stress-experiences among intensive care patients Sven-Tore D. Fredriksen a,∗, Karin C. Ringsberg b a
Harstad University College, Institute of Health and Social Sciences, Havnegata 5, 9480 Harstad, Norway b Nordic School of Public Health, Box 12133, SE-402 42 Gothenburg, Sweden Accepted 15 September 2006
KEYWORDS Hermeneutic; Intensive care nursing; Phenomenology; Stress; Experience
Summary The study is about the types of stress that patients in intensive care units experience. Ten reviewed articles selected from Cinahl and Pubmed between 1994 and 2003 constitute the data. The paper is a literature review, and the data is analysed from the phenomenological—hermeneutical point of view. Stress related to the body, room and relationships is discussed. Experiences of stress that are related to the body include bodily stress reactions, deprivation of control, emotions related to technical equipment, procedures and loss of meaning. Stress related to the room highlights the environment and the situation in which the patient finds him/herself. The ethical relations of professionals and separation of patients from their significant others constitute stress related to relationships. © 2006 Elsevier Ltd. All rights reserved.
Introduction Serious disease or severe trauma often lead to life-threatening conditions. These are far beyond everyday experience. They can be experienced as stressful, particularly when a person is removed from the safety of his/her home and sent to an intensive care unit, an environment which can be experienced as unfamiliar, strange and frightening. In a scientific context, stress is referred to ∗
Corresponding author. Tel.: +47 77 05 83 25; fax: +47 77 05 81 04. E-mail address: [email protected] (S.-T.D. Fredriksen).
and is applicable in the natural sciences, as well as in the hermeneutic scientific tradition (Lazarus, 1993). Research on stress within health science has focused on physiological and psychological factors. Instead of seeing stress as the sum of variables describing conditions in the person or environment, this study explores how intensive care is experienced and interpreted by the patients and what the meaning of the situation might be for them. Stress appears when the patient loses the meaning of the situation (Lazarus and Folkman, 1984; Lazarus and Launier, 1978). Being a victim of trauma or having severe disease is a condition, but it can also be described as an existence, a way to relate to the world (Eriksson,
0964-3397/$ — see front matter © 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.iccn.2006.09.002
Stress experiences among intensive care patients 2002). According to Ricoeur (1988), man is related to an exterior world and an inner world at the same time, which constitutes the lifeworld. Relating to something means being extrovert and introvert at the same time. Living a situation, especially one that threatens one’s life and health, often activates former stressful experiences. Seen from a phenomenological perspective, these experiences remain and are always present in the body giving the body both reflective and physical dimensions (Merleau-Ponty, 1994). The physically reflective body, as it is referred to in this article, will react, experience and embody different elements of the situation in many different ways. People are always in a situation, and each situation provides different sets of experiences (Benner and Wrubel, 2001). Person and situation become one through the experiences the person defines as significant or non-significant. The body assimilates experience through sensations present in the situation as the focus of attention. The body is positioned in the situation. Man exists, acts and reflects as a living body (Heidegger, 1992; Engelsrud, 1990). In a sensuous presence with others, relations with others appear. Relating to others includes reciprocity by being in the world together. In this kind of relationship, the body performs a double function in its relationship to others; being touched and touching, it observes and it is observed (Martinsen, 1993). The physical body links the intensive care patient to the intensive care room and by its experiences it becomes omnipresent in the room (Benner and Wrubel, 2001). For the intensive care patient, this involves being in a room which captures the attention of the physically reflective body. The extent of sensation will determine whether the body can push the experience of diseases aside and thus focus on the world beyond. The body’s alternative is to focus inwards, towards a ‘‘bodily space’’ in which it becomes more aware of itself. The body exists at the same time in two aspects of the lifeworld (Leder, 1990). These two lifeworlds represent two separate sets of levels; one objective level and one phenomenological level. They share the fact that they are both caught up in the attention of the person’s mind. Much research has been associated with intensive care patients’ physiological reactions to stress and from a quantitative approach (Tracy and Ceronsky, 2001; Honkus, 2003; Baxter, 2004). However, it is also important to listen to those who have the lived experience of being a patient in an intensive care ward. The purpose of the present study was to describe the kind of stress patients in intensive care experience in relation to the body, room and relationships.
125
Method This article is a literature review. The Pubmed and Cinahl databases were used and the search covers the period 1994—2003. The search words were ‘‘intensive care patients’’ and ‘‘stress’’. The selection of articles was made in two steps.
Inclusion criteria The articles should: 1. be published in English and in journals with a referee system; 2. refer to adult patients >19 years of age; 3. be review articles; 4. describe the dimension of the lifeworld. Twenty hits were found in Pubmed and 10 in Cinahl.
Exclusion criteria The articles should not refer to: 1. diagnoses; 2. treatment strategies. This excluded 14 articles from Pubmed and 6 from Cinahl. The study thus includes a total of 10 articles, 6 from Pubmed and 4 from Cinahl. For details on the articles included, see Table 1.
Analysis The articles were analysed from a phenomenological—hermeneutical approach (Heidegger, 1992; Merleau-Ponty, 1994; Benner and Wrubel, 2001). This means that the researcher has a kind of dialogue with the texts with the purpose of understanding them (Gadamer, 1979; Lindseth, 1981). In the interpretative process, the researcher uses his/her empirical preconceptions. The two authors of the present study have several years’ experience of working in intensive care units as a nurse and a physiotherapist. The following three key questions were raised in relation to the articles: 1. How is the body experienced during serious disease? 2. How is the room experienced during serious disease? 3. How are relationships experienced during serious disease? The results are discussed under three main headings: physical experiences, experiences of the room and experiences of relationships. The first author had the main responsibility for collecting and analysing the data. The data have been con-
126 Table 1
S.-T.D. Fredriksen, K.C. Ringsberg Overview of the 10 review articles on stress and intensive care unit (ICU) patients included in the study
Reference
Honkus (2003)*
Tracy and Ceronsky (2001)*
Clarke and Harrison (2001)*
Black et al. (1997b)*
Nelson (1997)*
The study’s purpose, results and conclusions, method of analysis and number of articles included Purpose: To explain sleep processes and the importance of sleep for ICU patients and how sleep could be promoted by changes in nursing procedures Result and conclusions: Sleep processes are complicated and these processes are often disrupted among ICU patients by light, noise, unease, pain, medication and nursing procedures. When it comes to respecting a person’s need for sleep, practices need to be changed and education provided for the various groups of professionals who work every day in ICUs. The theme also needs to be addressed at academic conferences Method of analysis and articles included: Qualitative approach, 31 articles Purpose: To initiate a process in which patients and their significant others would experience extra support through improved communication and involvement with health care professionals. The purpose was also to increase their knowledge of stress and crisis management Result and conclusions: By using problem-solving processes, patients, significant others and health professionals experienced improved conditions in the ICU. Positive changes took place in the ICU, expressed by the professionals as an increased knowledge of working with patients and significant others. Furthermore, the professionals also improved their knowledge of communication through positive activities Method of analysis and articles included: Qualitative approach, 13 articles Purpose: To identify specific nursing actions to satisfy children’s need to visit the ICU Result and conclusions: Several actions were considered to be important for increasing the knowledge of child communication about health and illness. Children need to be prepared as well as protected from the sensuous impressions of an ICU. Information material needs to be improved and the waiting room must be adapted to children’s needs Method of analysis and articles included: Qualitative approach, 28 articles Purpose: To validate the term sensoristrain, examine its character and characteristics, clarify and illuminate its dichotomy in view of its elements, identify an operational definition of the term applicable to nursing and science and factors which may have changed the term over an extended period of time Result and conclusions: The term must be understood in its double meaning; as sensing and as a physical condition under severe stress. The term could be given additional content by understanding terms like stress, deprivation, overburdening and equilibrium. Reactions caused by sensoristrain in ICU patients were emotional conditions, sympathetic reflexes and a reduced ability to make decisions Method of analysis and articles included: Qualitative concept analysis, 14 articles Purpose: To discuss how an ethical environment could be created as an essential precondition for specific ethical issues derived from specific situations in ICUs Result and conclusions: The focal point was the relationships between physicians and nurses and how patients and their significant others were involved in clinical decisions. In co-operation, respect, integration and communication are as important among physicians, as they are between the physician, the nurse and the patient. Creating a good ethical working environment would not only serve the patient and his significant others, but it might also help the professionals in intensive care to find their work more meaningful Method of analysis and articles included: Qualitative approach, 27 articles
Stress experiences among intensive care patients
127
Table 1 (Continued) Reference
Soehren (1995)*
Powell (2002)ˆ
Curtis (2002)ˆ
Black et al. (1997a)ˆ
Suominen and Leino-Kilpi (1995)ˆ
* ˆ
Articles from the PUBMED. Articles from the Cinahl.
The study’s purpose, results and conclusions, method of analysis and number of articles included Purpose: To clarify which factors were perceived as stressful among patients undergoing heart surgery in an ICU Result and conclusions: Some main factors were found. Maximum stress was found in the patients’ lack of ability to control their situation and in having lost a spouse or partner. Moderate stress was seen due to nasal or oral intubation. Other stressors that were described were the need for extubation, suction procedures, noise and insomnia Method of analysis and articles included: Quantitative descriptive design (n = 43, 34 male, 9 female), 7 articles Purpose: To study literature in order to identify nursing methods which would provide intensive care patients with long-term well-being after hospital treatment Result and conclusions: The recovery phase for intensive care patients was both complex and dynamic. An holistic approach to post-treatment management is required. Nursing often focused on the diagnosis, but this approach did not solve patient problems. ICU wards should take a more active role towards this group of patients, including formal discharge procedures from hospital Method of analysis and articles included: Qualitative approach, 10 articles Purpose: To discuss parametric measurements and consequences of treatment with mechanical respiratory assistance Result and conclusions: The main goal for intensive care treatment is survival. The diagnosis predisposes many patients to critical illness, including manual respiratory treatment. The condition may also affect the patient’s general quality of life and bodily functions long after intensive treatment. This requires the mapping of treatment and procedures in order better to identify improved and more efficient care. Highlighting these consequences was found to be important from a theoretical and a practical perspective. Post-mechanical ventilation traumas ought to be more thoroughly investigated Method of analysis and articles included: Qualitative approach, 69 articles Purpose: To analyse patient experiences of sensoristrain and nurses’ practical roles in an ICU in the light of Neuman’s theory, with special emphasis on stress in order to clarify and provide guidance for everyday practice Result and conclusions: Neuman’s theory was found to be relevant as a model for examining sensoristrain among intensive care patients. In the current economic climate, advanced nursing should emphasise professional values and articulate the contribution nursing intervention represents — and above all show that nursing involves not only caring for the physical body but also a humanistic effort of which knowledge of the body is an essential part Method of analysis and articles included: Qualitative approach, 40 articles Purpose: To study the scientific papers that appeared in Intensive and Critical Care Nursing (ICCN) in 1985-1991 and to compare this published research with what Finnish staff nurses in ICUs would have liked to prioritise as areas for research Result and conclusions: The main problems for intensive care nurses are coping and developing professional skills and quality of care, while the papers published in the ICCN focus on staff-related research and stress. The 1980s and 1990s focused on patients, while the current need is to focus on stress among staff. Communication skills could provide greater satisfaction among staff. More research on intensive care nursing in Europe is needed Method of analysis and: Qualitative approach, 294 articles
128 tinuously discussed by the two authors. Both have been responsible for writing the article.
Findings The organization of the findings are based at the key question in the article, i.e. stress related to the body, room and relationships. The section also contains reflections, but these are of a more overall level.
Experiences of the body Bodily reactions We and our bodies are always in a situation, according to Benner and Wrubel (2001). Being in a situation, being seriously ill and being a patient in an ICU influences the body, which is described as stressful. When the body is ill, especially seriously ill, physical changes occur. In the articles, patients describe stress reactions like sweating, increased heart frequency, hyperventilation and restlessness. Body in a phenomenological context also includes being a body, not merely having one. By being a body, we exist in and with the body. When an intensive care patient experiences physical reactions from the sympathetic nervous system, the reflective body’s nature will be turned against the experiences of these reactions. The experiences will thus be embodied and ‘‘wake up’’ the person’s attention (Merleau-Ponty, 1994). The body’s ability to recognise former experience, by its embodied knowledge, enables it to ‘‘wake up’’ when similar yet different experiences occur in a new situation. The bodily sensations do not make sense, but the lack of sense creates a stress response (Benner and Wrubel, 2001). Insomnia is another physical phenomenon which is described in the situation. Procedures, care provision and noise around the patients prevent them from sleeping. Sleep has a healing effect on the body through several bodily functions, but sleep is also an expression of the body’s self-regulating nature. When external factors determine the life conditions of the ‘‘private room’’ and the ‘‘physical room’’, the patient’s need for sleep becomes invisible. Man perceives the world around him with his body and its senses. Disturbed sleep forces the senses into action. Sleep itself shuts the senses down and prevents the body from perceiving the world, keeping the world out. Deprivation of control The articles also describe other physical reactions to being deprived of control, including fear and pain. These phenomena are frequently seen
S.-T.D. Fredriksen, K.C. Ringsberg in severely ill patients. Losing control of the situation is often experienced as a threat by the patients. Understanding oneself, in a phenomenological way, means understanding oneself retrospectively. One situation is often linked to former situations and its meaning is often interpreted by earlier experiences. Fear and pain not only express changes and reactions in the body, they are also far-reaching consequences of the effects these phenomena have on the entire self. Phenomena and situations merge and are visible in the individual’s recognition of fear and pain. Recognition provides contact with the body, not only because man lives in a body — but because the body itself lives in man. Stress occurs when the body meets negative recognition. Emotions on technical equipment and procedures Technical equipment and procedures used to sustain vital functions were also experienced as stressful by the ICU patients. It relates, for example, to respirators, intubation and cleaning respiratory tracts. For some patients, mechanical respiration with the assistance of a machine might symbolise security and a promise of life, for others an experience of trauma and fear by being bound to this machinery. Being in the situation may even provoke emotional reactions in patients. Patients also experience a reduced ability to see opportunities or an ability to make decisions, fear of being stuck in a situation, confusion and in some cases hallucinations. Loss of meaning It is often difficult to live a situation in which many factors appear to be without meaning. Meaningfulness helps man to understand a situation and the reason why man exists. The reflected body applies its vocabulary to find meaning and, when it does not do so, stress occurs. When the body and its potential for action experience limitations in functionality, this affects the body’s life, sustainability and future. A severely ill person cannot move his body away from the situation, but, in critical situations, when the situation becomes overwhelming, the mind may provide an escape from the situation by moving out of the body with its thoughts.
Experiences of the room Bodily senses Stress originating from the character of the room is described in the articles. The intensive care unit is a special environment. The situation is created
Stress experiences among intensive care patients by the room the body perceives through its senses and the persons in it. The situation is also affected by the position from which the body senses the room. Lying in a bed gives a different perception of the room than standing upright. Being in the room means embodying the situation and reaching out to the room with one’s body (Merleau-Ponty, 1994). The intensive care room as a room and context carries no meaning in and of itself. However, it is given meaning through social and cultural contexts, being alive yet being critically ill (Gjengedal, 1994). Through the body’s experience of two simultaneous existences, being alive and being seriously ill, the intensive care room reaffirms the existence of life and being in it. The body is able to feel this combined existence through sensuous confirmation. When the situation is impressed by strong light and troublesome noise and when the patient’s significant others are not integrated with the patients, this clearly contrasts to the prerequisites of the patient. Stress occurs when light becomes bothersome from the patient’s perspective in the bed, since horizontal and vertical light sensations are very different. Important sounds become indistinguishable from noise and create a sense of meaninglessness, since a horizontal position also enforces phenomena like power and powerlessness. In this context, power should not be regarded in a traditional paternalistic way, but by the body’s own opportunity to sustain life. The aspect of power can be illustrated by the critically ill body falling victim to its own situation as critically ill. The strain on the body in a situation like this is imposed on it and the body has no way of affecting the outcome of the situation in any particular way. The situation and all its elements take control of the body. Powerlessness is the sum of experiences and the physical limitations of the horizontal position of the body in the room. This position limits the body’s opportunities in terms of its functions, as responsive to the demands and expectations often associated with life preservation.
Experiences of relationships Disturbances in relation Relation-based stress is described in articles linked to situations related to the observation of the patients, care provision and treatment. These often occur simultaneously. Patient observation procedures are often experienced by the patients as more stressful than light or noise. The way care is organised often affects the satisfaction of elementary physical needs in the patient, as well as his/her fear and anxiety. Patients and their significant others rate continuity of care and the proximity of
129 nurses and physicians as very important. Continuity may be disturbed by ethical or professional differences between nurses and physicians. The close relationship is essential in terms of safety as well as hope. Disturbances are often caused by how busy the situation is. An atmosphere of being busy may change the sense of a ‘‘room’’ being filled with hope and safety to a ‘‘room’’ with a lack of care. This affects significant others, the patient and the care provider’s tasks. People are created for each other and thus demand help from each other (Martinsen, 1993). Being critically ill means being dependent on assistance with life-supporting actions a person is unable to perform by him/herself. In this situation, nurses and significant others become the arms and the identity of the patient—–the nurses by acting on behalf of the patient and significant others by knowing the patient’s personality and habits. The lack of feeling significant or deprived of continuous contact and separation from one’s loved ones can be experienced as stress. In one article, significant others refer to similar experiences. The bodies of the patients and their significant others sense each other’s state of mind. In this way also, the relational experiences are made significant. Even if the situation may not be perceived identically, these phenomena are important to people who experience the situation. As a consequence, situational phenomena may be characterised as stress or potential stress induced in both patients and their significant others. Relation and communication are often connected. Different characteristics of the situation’s relational dimension are referred in the articles. Intensive care patients are often unable to express themselves verbally because they are intubated. Words make a person visible to others (Lillestø, 1997). The body is accustomed to expressing itself in words and actions. When words cannot be expressed and the body’s power of movement is limited by critical illness, helplessness may manifest itself by experiencing a lack of meaning and stress.
Discussion Benner and Wrubel (2001) claim that knowledge is embodied. This implies that the body affects the mind, as the mind affects the body. Stress comes from the person’s relationship to the situation and his/her abilities to adapt to it. Ten review articles (see Table 1) were analysed from a phenomenological—hermeneutical angle to determine how stress is experienced by intensive care
130 patients from three different approaches, related to: (1) the body, (2) the room and (3) relationships. The quality of the articles appeared to be different in terms of the description of methodology. In spite of this, all the articles have been judged to be valid. Physical responses in patients described in the articles were perspiration, increased pulse, hyperventilation and restlessness. Leder (1990) applies the term ‘‘disappearing body’’ to describe the condition the body experiences. It is captured in experiences demanding attention. The body’s appearance is dysfunctional, since its senses make it the sole object of attention. When the body considers itself, the body becomes estranged and unrecognisable. The body moves from being attentive in the room outside to focus on its internal room. Such changes to ‘‘being in the world’’ often feel meaningless and induce stress. Stress related to the body also includes insomnia. Being deprived of the body’s rhythmical patterns of activity, rest and sleep, in addition to being seriously ill, is an added strain. The time of sleep and the reduced quality of sleep was described as one of the most serious stress factors. As different to a patient suffering from stroke, the intensive care patient has not lost his/her embodied knowledge. Nor has he/she, as is seen in patients with dementia, lost his/her ability to make use of this knowledge. However, the intensive care patient’s body is not given the opportunity to maintain its strength and reconstitute itself through the provision of regular sleep and rest. Anxiety and pain were also described as other dimensions of stress. These are phenomena beyond their obvious physical effects; they affect the whole being. Pain and anxiety make contact with the body and the body becomes the focus of the attention. Pain and anxiety also affect the structure of the body. Depending on their expressions and intensity, they may — together or separately — constitute a threat to the body’s survival. The articles also described intensive care patients being exposed to mental stress. Heidegger (1992) refers to man’s ‘‘being in the world’’ as a kind of confidence in one’s surroundings and loved ones. This confidence is expressed by pre-reflexive and immediate responses. When the intensive care patient encounters a situation which tunes the body to a specific sensation, for example, when acute/critical illness threatens the being’s survival, stress appears as immediate life utterances like concern, resignation or psychosis. Stress can also appear as a reaction related to the treatment itself, such as when the patient is on life-support machinery. By living in the body, unable physically to remove oneself from the situation, the experience
S.-T.D. Fredriksen, K.C. Ringsberg becomes overwhelming. The search for meaning makes the intentional individual look for potentially new solutions. His/her life utterances are a confirmation of this search. The search for solutions involves numerous stress experiences, that include a loss of understanding and meaning in the situation. According to Merleau-Ponty (1994), the body is not present in the room but lives the room. The intensive care patient perceives the room with his/her body’s senses and can reach out into the room with his/her body’s ability to influence its environment. In such a dynamic, the body’s potentials will be focused in various ways. What the body encounters provides information about the body’s condition when it meets the room. The body thus becomes its own focus of attention. Intensive care patients usually meet the room in a horizontal position. The light is stressful because its appearance to the bedridden patient is not to light up the room but rather to shine in the eyes. Nor will he/she experience light regulating his embodied knowledge of changes between night and day. When unfamiliar and intense sounds reach the body and its mind, their alien character produces stress. The room also changes the person’s relational needs versus significant others. Being cut off from normal relationships means being deprived of opportunities for sharing. Sharing is a natural process in the living world, as well as in the room to which the intensive care patient is confined. This separation from sharing brings out the question of power and lack of control. Power is illustrated by the patient’s constant reminder that he is separated from his loved ones. Lack of control is illustrated by his/her body’s limitations in the room and the experiences such limitations produce. According to Løgstrup (2000), all life revolves around being in or dealing with relationships. Life was created in order to ‘‘receive the other’’. This philosophy emphasises that people are made for each other and to care for one another. In an ICU, life utterances appear in the relationship between staff internally and with the patient in varying degrees of proximity, continuity and predictability. They also appear when there are conflicts among staff or when management or continuity in care fails. Relationships may be strengthened by good professional care and observation of the patient, but also by including the patient’s loved ones, including children. Threats to the relationship may affect the stress condition in the intensive care patient and worsen his/her condition. This stress is particularly complicated, as the patient is often unable to express his/her needs in words when he/she is on life-support machinery.
Stress experiences among intensive care patients
Conclusion and clinical implications This article shows that intensive care patients experience several types of stress related to the body, the room and their relationships with others, experiences that are integrated in the patient as the reflected body. This stress is vitally important to the patient’s experience of body and situation and is often threatening to his/her existence. Being trapped in a condition of stress can affect the ICU patient’s situation dramatically, because of small margins. In a clinical context, this experience-based knowledge is important, since it can be decisive for the patient’s situation. The patients are influenced because what they experience and perceive in the situation is not seen and understood by the professionals since their experienced-based knowledge to a large extent is absent. This leads to a relational discourse which is observing and where the patients with their marginal opportunities are excluded. The patient often experiences this as a dramatization of her situation which in turn may lead to loss of willpower, capability and vitality. The experienced-based knowledge therefore has another status than the observing knowledge precisely because it changes with the constantly perceiving patient. Such a dialectic knowledge might also appear and influence relations by having an effect on the patient—professional relationship. To be able to observe, understand and apply experience-based knowledge where it is needed requires practicing being influenced. The best way of doing so is in situations where knowledge can be gathered. Sensation perceptive knowledge should be encouraged, not only on a practical and professional level, but also within education. More research is needed to describe the different phenomena experienced by the patient in an intensive care context. Research is also required exploring how knowledge is transferred in an educational situation involving the patient.
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