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‘Take me away from all this’ … can reminiscence be therapeutic in an intensive care unit?
'Take me away from all this' ... can r e m i n i s c e n c e be
therapeutic in an intensive care unit? Colin Jones
• 'Is reminiscence therapeutic?' • 'Does it have psychological benefits?' • ' W h y do we reminisce?'
'Stuart had been with us in the ICU for 4 weeks; weaning attempts from his artificial ventilation were difficult, leaving him frightened, exhausted and despondent. Depression, hopelessness and apathy were beginning to take a hold on h i m . . , until one day something changed everything. A way had been found to help him escape, temporarily, from his intensive care situation. Three days later Stuart was breathing spontaneously and was being prepared for discharge from the ICU. ' In this paper potential benefits of reminiscence sessions with patients in a critical care unit are discussed. Background and context are reviewed, leading to some suggestions for practice.
INTRODUCTION R e m i n i s c e n c e ... is it more than just reliving t h e past?
Colin Jones BA(Hons)RN, CercEd, ENB 100, Senior Lecturer Critical Care Nursing, The LiverpoolJohn Moore's University, 79 Tithebarn Street, Liverpool L2 2ER, UK (Requests for offprints to CJ) Manuscript accepted I I September 1995
time. Quite often people 'travel back in time' to think and talk about pleasurable life experiences such as holidays, time spent with friends, or favourite evenings/days out. Talking about the past frequently evokes feelings of actually 'being there' and we derive pleasure from sharing the 'reliving' of the occasion with other people. Comments such as 'Oh! you should have been there', or 'I can see it now ... as clear as if it was yesterday' indicate active 'engagement' in a reminiscent episode (Kovach 1991). From our own experience, it seems feasible that a patient in an I C U may be able to escape their predicament temporarily using reminiscence as a vehicle to 'get away from it all'. Over the past 30 years there has been an increase in nursing research exploring the intriguing subject o f reminicence. Research questions under review have included:
Reminiscence and reminiscence therapy are areas which may not receive a great deal of attention in an intensive care unit (ICU). Reminiscing is more frequently associated with the elderly where it is viewed as a negative consequence of growing old (Bramwell 1984). According to Brewer (1986), 'Reminiscence is a cognitive process of recalling events from the past that are personally significant and perceived as reality based. Visual imagery is frequently used in reminiscing'. Almost everyone reminiscences at some
Intensive and Critical Care Nursing (r 995) I, 341-343
© 1995PearsonProfessionalLtd
Whilst the general findings of many research projects have been inconclusive in determining answers to these questions, a number of recent studies have shown that reminiscence can have a positive effect on self esteem and in empowering the individual who reminisces (Kovach 1991, Lowenthal & Marrazo 1990). In a classical study by McMahon & Rhuddick in 1964 it was found that reminiscence was positively correlated with maintenance of self esteem, re-affirmation of self identity and working through personal losses, and these key areas could be particularly pertinent to an intensive care patient.
Reminiscence and t h e intensive care patient-drawing some parallels Numerous authors have suggested that re-living significant life events can lead to feelings of increased self worth, sense o f pride and accomplishment and increased life satisfaction in elderly subjects (Keddy 1988, Merriam 1990), so it would seem appropriate to explore the potential benefits that reminiscence may have for patients in an intensive care context. It does not seem unrealistic to develop perceptions o f power, strength and motivation by utilising the patient's bank o f positive life experiences. A patient in an intensive care unit finds himself in an unfamiliar and futuristic technological world. Dyer (1995) very expertly illustrated the analogy between I C U and torture, and gave alarming examples of what may happen to patients if nurses are not vigilant. Feelings o f confusion and/or depersonalisation are c o m m o n and are associated with the familiar I C U Syndrome (Mackellaig 1990), though occasionally some patients may experi-
342.
Intensive and Critical Care Nursing
ence unusual states of 'mystical consciousness' (Noyes et al 1979) where powerful feelings-of joy, sharp vivid images, colours, and sensations of unity and harmony feature. During this time of psycho-emotional turbulence the patient may long to return to a better times, maybe with family and friends; a temporary escape to a happier real world. In this context reminiscing may have many positive psychological benefits. It is crucial to consider the entire picture of the patient's critical care experience before engaging the patient in a reminiscent episode, in order that the correct time and recovery stage is chosen. R e m i n i s c e n t e p i s o d e s in t h e I C U how could they be useful?
It is vital to appreciate that the kind of reminiscent episode undertaken with the I C U patient should emphasise positive aspects of life and encourage positive thoughts and feelings. Following this format, the reminiscent episode can be akin to the concept of 'milestoning' (Lowenthal & Marrazo 1990) in which negative memories are counterbalanced with positive ones. Reminiscence should not be confused with a more analytical intervention called life review (Butler 1963) which requires patients to review their entire life to deal with unresolved conflict. The aims o f a reminiscent episode with an I C U patient are different (Table 1). Clearly, the time has to be appropriate to initiate an episode of reminiscence, and the nurse should use professional judgement in determining this time with the patient, The use of reminiscence may be particularly useful with long term patients who are at risk of becoming despondent and depressed with the nature of the lengthy and exhausting essential management of their illness. In an ideal world, the patients would be able to reminisce verbally and tell their stories, though it has been shown that reminiscence has an additional 'silent' component, which may have lasting value for the individual
~!~::;:~:#~:#:;:!:#~i~:~:;:~:~!~;:~:~:~:~:!:~:~i~:~:~i~i:::::::::::::i:##:~i!:!:#:~i~:~:#:~:~:~)i~i~:!i~:#:;:i):~:!i~:~:~:~:~:!i!:~:~:#:~:~:~i~i!:~i~i~:~i~i~:!i!:~:;:~
iiiiiiiiii!!N ii ii! iii NNi!iNiii! Niiiii! iiiiiiNiii!i ii!i!iii Holiday snapshots Old family photographs-with groups of family members to encourage thought/talk Souvenirs from happier times i. e. cinema, theatre programmes etc.
Significantmedia coverage in newspapers etc. Items of clothing... (Do you remember wearing this shirt/dress etc?)
(Havighurst & Glasser 1972). In the author's experience the family can play a key role when assisting in a reminiscent episode by prompfng the patient to remember the event, and participating in reliving the experience. The patient may also wish to become more involved by the use of pen and paper and other aids to communication. It is important to note that during a reminiscent episode, the patient is required to use higher cognitive centres, and it has been suggested that the use of higher cognitive centres may reduce the effects of sensory imbalances (Barrie-Shevlin 1987). It may be appropriate to choose a time when the patient is not too tired, perhaps before, or even during, difficult or unpleasant procedures such as weaning from ventilation or dressings/hne insertions. The positive images created by the reminiscent episode may then be used to balance the negafve nature of the I C U event. Reminiscent episodes can be triggered in a number of ways, though Table 2 indicates some of those most commonly used. Frequently, the patient and family may spontaneously enter into a reminiscent episode, and the I C U nurse is in a unique position to utilise the moment to empower and support the patient. It is important that the nurse allows the patient and family to reminisce freely, though the overall process should be discreetly 'supervised'. Remember the object of the exercise, to empower and support, increase feehngs of self worth and self value, and to provide the patient with a temporary escape from the I C U situation. Occasionally, reminiscent episodes will generate some sadness and the nurse should be aware of this and remember the balancing nature o f the intervention. Frequently, feelings of sadness can be resolved by assisting the patients to realise their own potential in helping themselves to recover; utilising reminiscent episodes which involve the patient succeeding at a past event can often be helpful in rekindling feelings of strength and motivation. To start with short periods of time should be devoted to the reminiscent episode, to allow the patient and family to feel comfortable with re-living the experience, and also to ensure that the patient is not exhausted,
iiliiiiiiiiiNiiiiwNiiiiiiii{iiiiii N {iii!iii{i!ii!ii!i{{iiiiiiiiiiiiiiiii{iiii!,;i {i{i{iii{i!ii{i!i;i!{i!i!ii{i{ii;ii{iiiiiii;{i{i iiiiiiiii{ iiiiiii{iiiiiii{iiiiiiiiiiiiii!ii ii ii{iiiiiiiii{l To encourage communication between patient and nurse
To encourage family involvement and participation in care
To release the patient temporarily from unfamiliar or
stressful surroundings To improve self esteem and feelingsof self worth To enhancethe rapport between nurse and patient To provide a temporary escape from the ICU
predicament
Can reminiscence be therapeutic in an intensive care unit? 343
experience; it assists individuals to r e m e m b e r happy times and makes people feel better. E v e r y o n e reminisces at some time in order to help p r o m o t e feelings o f worth, value and c o n tribution to society. I C U nurses are very familiar with the changes that occur in patients' life roles and the families' role during critical illness, and at a time w h e n m a n y patients feel defeated and hopeless re-living past experience may give t h e m the injection o f life energy they so desperately need.
REFERENCES
D u r i n g the reminiscent episode the nurse is able to make an assessment o f the patient's psycho-physiological state, such as h a e m o d y n a m i c parameters, m o o d , expression and willingness to c o m m u n i c a t e . All o f these variables make a valuable contribution to the overall assessment o f an I C U patient. T h e nurse can identify and use important e m p o w e r m e n t issues w h i c h occur during the course o f a reminiscent episode. These may include n o t i n g the ways in w h i c h the patient has c o p e d w i t h the situation, discussing progress no matter h o w small and identifying and emphasising the patient's strengths. Pickrel (1989) suggests that ' M a n y people emphasise the negative aspects o f their lives and o v e r l o o k the positive, focussing on the half e m p t y glass rather than the half full one'.
CONCLUSION Generally speaking, reminiscence is a positive
Barrie-Shevlin L 1987 Maintaining a sensory balance for the critically ill patient. Nursing 16:567-601 Bramwell L 1984 Use of the life history in pattern identification and health promotion. Advances in Nursing Science 7(1): 37-44 Brewer W 1986 What is autobiographical memory? In: Rubin, Autobiographical memory. Cambridge University Press, New York, 25-49 Butler 1K 1963 The life review"an interpretation of reminiscence in the aged. Psychiatry 26:65-76 Dyer I 1995 Preventing the ITU syndrome or how not to torture an ITU patient (Part 1). Intensive and Critical Care Nursing 11:130-139 Havighurst IK, Glasser tK 1972 An exploratory study of reminiscence. Journal of Gerontology 27(2): 245253 Keddy B 1988 The benefits of oral histories. Geriatric Nurse 9:i70-171 Kovach C 1991 Reminiscence behaviour an empirical exploration Journal of Gerontological nursing 17(12): 23-27 Lowenthal R, Marrazo 1K 1990 Milestoning: evoking memories for resocialisation. The Gerontologist 30(2): 26%272 MackellaigJ 1990 A review of the psychological effects of intensive care on the isolated patient and his family Care of the critically ill 6(3): 100-102 McMahon A, 1Khuddick P 1967 Reminiscing:adaptational significance in the aged. Archives of General Psychiatry 10:292-298 Merriam S 1989 The structure of simple reminiscence The Gerontologist 29(6): 761-767 Noyes IK, Slymen D 1979 The subjective response to life threatening danger. Omega 9(4): 313-321 PickrelJ 1989 Tell me your story: using life review in counselling the terminally ill. Death studies 12: 127135
therapeutic in an intensive care unit? Colin Jones
• 'Is reminiscence therapeutic?' • 'Does it have psychological benefits?' • ' W h y do we reminisce?'
'Stuart had been with us in the ICU for 4 weeks; weaning attempts from his artificial ventilation were difficult, leaving him frightened, exhausted and despondent. Depression, hopelessness and apathy were beginning to take a hold on h i m . . , until one day something changed everything. A way had been found to help him escape, temporarily, from his intensive care situation. Three days later Stuart was breathing spontaneously and was being prepared for discharge from the ICU. ' In this paper potential benefits of reminiscence sessions with patients in a critical care unit are discussed. Background and context are reviewed, leading to some suggestions for practice.
INTRODUCTION R e m i n i s c e n c e ... is it more than just reliving t h e past?
Colin Jones BA(Hons)RN, CercEd, ENB 100, Senior Lecturer Critical Care Nursing, The LiverpoolJohn Moore's University, 79 Tithebarn Street, Liverpool L2 2ER, UK (Requests for offprints to CJ) Manuscript accepted I I September 1995
time. Quite often people 'travel back in time' to think and talk about pleasurable life experiences such as holidays, time spent with friends, or favourite evenings/days out. Talking about the past frequently evokes feelings of actually 'being there' and we derive pleasure from sharing the 'reliving' of the occasion with other people. Comments such as 'Oh! you should have been there', or 'I can see it now ... as clear as if it was yesterday' indicate active 'engagement' in a reminiscent episode (Kovach 1991). From our own experience, it seems feasible that a patient in an I C U may be able to escape their predicament temporarily using reminiscence as a vehicle to 'get away from it all'. Over the past 30 years there has been an increase in nursing research exploring the intriguing subject o f reminicence. Research questions under review have included:
Reminiscence and reminiscence therapy are areas which may not receive a great deal of attention in an intensive care unit (ICU). Reminiscing is more frequently associated with the elderly where it is viewed as a negative consequence of growing old (Bramwell 1984). According to Brewer (1986), 'Reminiscence is a cognitive process of recalling events from the past that are personally significant and perceived as reality based. Visual imagery is frequently used in reminiscing'. Almost everyone reminiscences at some
Intensive and Critical Care Nursing (r 995) I, 341-343
© 1995PearsonProfessionalLtd
Whilst the general findings of many research projects have been inconclusive in determining answers to these questions, a number of recent studies have shown that reminiscence can have a positive effect on self esteem and in empowering the individual who reminisces (Kovach 1991, Lowenthal & Marrazo 1990). In a classical study by McMahon & Rhuddick in 1964 it was found that reminiscence was positively correlated with maintenance of self esteem, re-affirmation of self identity and working through personal losses, and these key areas could be particularly pertinent to an intensive care patient.
Reminiscence and t h e intensive care patient-drawing some parallels Numerous authors have suggested that re-living significant life events can lead to feelings of increased self worth, sense o f pride and accomplishment and increased life satisfaction in elderly subjects (Keddy 1988, Merriam 1990), so it would seem appropriate to explore the potential benefits that reminiscence may have for patients in an intensive care context. It does not seem unrealistic to develop perceptions o f power, strength and motivation by utilising the patient's bank o f positive life experiences. A patient in an intensive care unit finds himself in an unfamiliar and futuristic technological world. Dyer (1995) very expertly illustrated the analogy between I C U and torture, and gave alarming examples of what may happen to patients if nurses are not vigilant. Feelings o f confusion and/or depersonalisation are c o m m o n and are associated with the familiar I C U Syndrome (Mackellaig 1990), though occasionally some patients may experi-
342.
Intensive and Critical Care Nursing
ence unusual states of 'mystical consciousness' (Noyes et al 1979) where powerful feelings-of joy, sharp vivid images, colours, and sensations of unity and harmony feature. During this time of psycho-emotional turbulence the patient may long to return to a better times, maybe with family and friends; a temporary escape to a happier real world. In this context reminiscing may have many positive psychological benefits. It is crucial to consider the entire picture of the patient's critical care experience before engaging the patient in a reminiscent episode, in order that the correct time and recovery stage is chosen. R e m i n i s c e n t e p i s o d e s in t h e I C U how could they be useful?
It is vital to appreciate that the kind of reminiscent episode undertaken with the I C U patient should emphasise positive aspects of life and encourage positive thoughts and feelings. Following this format, the reminiscent episode can be akin to the concept of 'milestoning' (Lowenthal & Marrazo 1990) in which negative memories are counterbalanced with positive ones. Reminiscence should not be confused with a more analytical intervention called life review (Butler 1963) which requires patients to review their entire life to deal with unresolved conflict. The aims o f a reminiscent episode with an I C U patient are different (Table 1). Clearly, the time has to be appropriate to initiate an episode of reminiscence, and the nurse should use professional judgement in determining this time with the patient, The use of reminiscence may be particularly useful with long term patients who are at risk of becoming despondent and depressed with the nature of the lengthy and exhausting essential management of their illness. In an ideal world, the patients would be able to reminisce verbally and tell their stories, though it has been shown that reminiscence has an additional 'silent' component, which may have lasting value for the individual
~!~::;:~:#~:#:;:!:#~i~:~:;:~:~!~;:~:~:~:~:!:~:~i~:~:~i~i:::::::::::::i:##:~i!:!:#:~i~:~:#:~:~:~)i~i~:!i~:#:;:i):~:!i~:~:~:~:~:!i!:~:~:#:~:~:~i~i!:~i~i~:~i~i~:!i!:~:;:~
iiiiiiiiii!!N ii ii! iii NNi!iNiii! Niiiii! iiiiiiNiii!i ii!i!iii Holiday snapshots Old family photographs-with groups of family members to encourage thought/talk Souvenirs from happier times i. e. cinema, theatre programmes etc.
Significantmedia coverage in newspapers etc. Items of clothing... (Do you remember wearing this shirt/dress etc?)
(Havighurst & Glasser 1972). In the author's experience the family can play a key role when assisting in a reminiscent episode by prompfng the patient to remember the event, and participating in reliving the experience. The patient may also wish to become more involved by the use of pen and paper and other aids to communication. It is important to note that during a reminiscent episode, the patient is required to use higher cognitive centres, and it has been suggested that the use of higher cognitive centres may reduce the effects of sensory imbalances (Barrie-Shevlin 1987). It may be appropriate to choose a time when the patient is not too tired, perhaps before, or even during, difficult or unpleasant procedures such as weaning from ventilation or dressings/hne insertions. The positive images created by the reminiscent episode may then be used to balance the negafve nature of the I C U event. Reminiscent episodes can be triggered in a number of ways, though Table 2 indicates some of those most commonly used. Frequently, the patient and family may spontaneously enter into a reminiscent episode, and the I C U nurse is in a unique position to utilise the moment to empower and support the patient. It is important that the nurse allows the patient and family to reminisce freely, though the overall process should be discreetly 'supervised'. Remember the object of the exercise, to empower and support, increase feehngs of self worth and self value, and to provide the patient with a temporary escape from the I C U situation. Occasionally, reminiscent episodes will generate some sadness and the nurse should be aware of this and remember the balancing nature o f the intervention. Frequently, feelings of sadness can be resolved by assisting the patients to realise their own potential in helping themselves to recover; utilising reminiscent episodes which involve the patient succeeding at a past event can often be helpful in rekindling feelings of strength and motivation. To start with short periods of time should be devoted to the reminiscent episode, to allow the patient and family to feel comfortable with re-living the experience, and also to ensure that the patient is not exhausted,
iiliiiiiiiiiNiiiiwNiiiiiiii{iiiiii N {iii!iii{i!ii!ii!i{{iiiiiiiiiiiiiiiii{iiii!,;i {i{i{iii{i!ii{i!i;i!{i!i!ii{i{ii;ii{iiiiiii;{i{i iiiiiiiii{ iiiiiii{iiiiiii{iiiiiiiiiiiiii!ii ii ii{iiiiiiiii{l To encourage communication between patient and nurse
To encourage family involvement and participation in care
To release the patient temporarily from unfamiliar or
stressful surroundings To improve self esteem and feelingsof self worth To enhancethe rapport between nurse and patient To provide a temporary escape from the ICU
predicament
Can reminiscence be therapeutic in an intensive care unit? 343
experience; it assists individuals to r e m e m b e r happy times and makes people feel better. E v e r y o n e reminisces at some time in order to help p r o m o t e feelings o f worth, value and c o n tribution to society. I C U nurses are very familiar with the changes that occur in patients' life roles and the families' role during critical illness, and at a time w h e n m a n y patients feel defeated and hopeless re-living past experience may give t h e m the injection o f life energy they so desperately need.
REFERENCES
D u r i n g the reminiscent episode the nurse is able to make an assessment o f the patient's psycho-physiological state, such as h a e m o d y n a m i c parameters, m o o d , expression and willingness to c o m m u n i c a t e . All o f these variables make a valuable contribution to the overall assessment o f an I C U patient. T h e nurse can identify and use important e m p o w e r m e n t issues w h i c h occur during the course o f a reminiscent episode. These may include n o t i n g the ways in w h i c h the patient has c o p e d w i t h the situation, discussing progress no matter h o w small and identifying and emphasising the patient's strengths. Pickrel (1989) suggests that ' M a n y people emphasise the negative aspects o f their lives and o v e r l o o k the positive, focussing on the half e m p t y glass rather than the half full one'.
CONCLUSION Generally speaking, reminiscence is a positive
Barrie-Shevlin L 1987 Maintaining a sensory balance for the critically ill patient. Nursing 16:567-601 Bramwell L 1984 Use of the life history in pattern identification and health promotion. Advances in Nursing Science 7(1): 37-44 Brewer W 1986 What is autobiographical memory? In: Rubin, Autobiographical memory. Cambridge University Press, New York, 25-49 Butler 1K 1963 The life review"an interpretation of reminiscence in the aged. Psychiatry 26:65-76 Dyer I 1995 Preventing the ITU syndrome or how not to torture an ITU patient (Part 1). Intensive and Critical Care Nursing 11:130-139 Havighurst IK, Glasser tK 1972 An exploratory study of reminiscence. Journal of Gerontology 27(2): 245253 Keddy B 1988 The benefits of oral histories. Geriatric Nurse 9:i70-171 Kovach C 1991 Reminiscence behaviour an empirical exploration Journal of Gerontological nursing 17(12): 23-27 Lowenthal R, Marrazo 1K 1990 Milestoning: evoking memories for resocialisation. The Gerontologist 30(2): 26%272 MackellaigJ 1990 A review of the psychological effects of intensive care on the isolated patient and his family Care of the critically ill 6(3): 100-102 McMahon A, 1Khuddick P 1967 Reminiscing:adaptational significance in the aged. Archives of General Psychiatry 10:292-298 Merriam S 1989 The structure of simple reminiscence The Gerontologist 29(6): 761-767 Noyes IK, Slymen D 1979 The subjective response to life threatening danger. Omega 9(4): 313-321 PickrelJ 1989 Tell me your story: using life review in counselling the terminally ill. Death studies 12: 127135