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Visits in an intensive care unit—An observational hermeneutic study
Intensive and Critical Care Nursing (2010) 26, 51—57
available at www.sciencedirect.com
journal homepage: www.elsevier.com/iccn
ORIGINAL ARTICLE
Visits in an intensive care unit—–An observational hermeneutic study Thomas Eriksson a,b,∗, Berit Lindahl c,d, Ingegerd Bergbom c a
CIVA/96, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Sweden c Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Box 457, SE-405 30 Göteborg, Sweden d School of Health Sciences, University College of Borås, Allégatan 1, SE-501 90 Borås, Sweden b
Accepted 24 September 2009
KEYWORDS Hermeneutics; Observations; Visitors to patients; Critical care
Summary Aim: The aim was to interpret the interplay between critically ill patients and their next of kin in an ICU and to disclose a deeper understanding of the visiting situation. Method: A hermeneutic research design with non-participant observation was chosen as the data collection method. Ten observations of 10 patients and 24 loved ones over a 20-h period were conducted. The text describing the observations of the interplay was interpreted in accordance with Gadamer’s thoughts. Data were analysed by considering the text as a play with scenes, actors and plots. Findings: Due to their medical condition the patients were unable to use their bodies in the usual way, which sends different signals to their loved ones, who in turn have difficulty deciding how to respond. Both parties become, in a manner of speaking, trapped or locked out by their own bodies. Conclusion: The physical environment became a hindrance to the interplay as it was designed for medical and technical use and thus did not promote healing. The professionals are important for interpreting the signals from both patients and next of kin, as well as for finding caring strategies, such as physical contact that promote interplay, which in turn strengthens connectedness. © 2009 Elsevier Ltd. All rights reserved.
Introduction ∗
Corresponding author at: CIVA/96, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden. Tel.: +46 31 342 16 84; fax: +46 31 41 44 83. E-mail addresses: [email protected] (T. Eriksson), [email protected] (B. Lindahl), [email protected] (I. Bergbom).
The patient is the most important person in intensive and critical care. He/she is ‘‘the suffering person’’; the one cared for and at whom the care is aimed. The patient’s world stands out as suffering (Eriksson, 1997). It is evident that loved ones are an important source of support for critically ill patients (Magarey and McCutcheon, 2005). In
0964-3397/$ — see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.iccn.2009.09.005
52 several international studies (Bergbom and Askvall, 2000; Eggenberger and Nelms, 2007; Engström and Söderberg, 2007; Ringdal et al., 2008; Storli et al., 2008; Williams, 2005), patients have stated that loved ones are vital because they motivate the patient to stay alive and continue the struggle for survival. Thus, the presence of loved ones is essential for the patient and must be encouraged by the nurses. An earlier study elucidated the extent to which patients have visitors. It was found that about 25% of patients did not have any visitors at all during their intensive care unit (ICU) stay. However, those patients were older and often lived alone (Eriksson and Bergbom, 2007). The number of such patients is increasing in ICUs today, and it seems logical to conclude that nurses have to care for a higher percentage of patients with no loved ones and/or visitors. In an interview study, Söderström et al. (2006) found that the initial interaction with the staff had a significant effect on family members and influenced not only their future relationship with the professionals, but also their ability to care for and motivate the patient. Mutual understanding and misunderstanding were two aspects of the interaction between family members and staff. Support from staff members enabled next of kin to use both internal and external resources to cope with having a loved one in the ICU. Having trust in themselves as well as encountering professionalism and charity gave the next of kin a sense of empowerment (Johansson et al., 2005). An interview study by Ågård and Harder (2007) revealed that the next of kin tried to manage a chaotic and frightening situation by attempting ‘‘to fit in’’. The issue of the presence and influence of patients’ next of kin in the ICU is an important and complex topic among ICU staff. There is consensus in the literature that visits by next of kin are beneficial for the patient and his/her family, but visiting procedures/routines vary between hospitals as well as countries (Latour, 2005). The large variation may be due to lack of compliance with scientific evidence as well as the current cost-cutting climate, which can result in a heavy workload and less time being devoted to the patients and their next of kin (Endacott and Berry, 2007). Another problem is that lack of nursing and medical staff leads to less time spent ‘‘caring’’ for the relatives, and nurses are neither trained nor prepared for such a relationship (Price, 2004; Williams, 2005). It is therefore of interest to obtain knowledge about caring in the interplay between patients and their next of kin in order to develop alternative forms of care and new strategies, i.e. what can we learn about caring from family members’ relationship and interplay when one of them is critically ill/injured? The professional and caring perspective in this study regards the human being as a whole, a unity of body, soul and spirit. Caring is natural and primordial and motivated by love and concern for fellow human beings.
Aim The aim was to interpret the interplay between critically ill patients and their next of kin in an ICU and to disclose a deeper understanding of the visiting situation.
T. Eriksson et al.
Method A hermeneutic method was used in this study. Hermeneutics is the classic discipline that deals with the art of trying to understand texts and attempts to reflect the humanistic, scientific way of understanding human beings’ cultural activities, i.e. relationships with other human beings (Gadamer, 1996). Texts are interpreted in order to grasp their meaning and thereby gain understanding with a view to traditions so that the historic dialogue of mankind can continue and become deeper (Helenius, 1990; Polit et al., 2001). A complex and nuanced world cannot be explained in exact terms, but only understood broadly (Eriksson, 1997). Both Gadamer (1996) and Løgstrup (1994) describe texts as a dimension of art; text creates a scene, which allows us to observe from the outside in the same way as a theatre play. This statement was the reason for the analysis process used in the present study. Gadamer (1996) talks about games and plays that bewitch, entrance and absorb so that one apprehends them as reality. This implies that one becomes a part of the game and what is fascinating is that the play governs the player (Selander and Ödman, 2004). A hermeneutic study implies that the interpretation and understanding of the data are based on the researcher’s existing knowledge and experience of the subject under investigation, i.e. prejudices. The role of the interpreter is to bring together the horizons of the past and present, i.e. a fusion of horizons. It is thus important that the researcher is aware of his/her own prejudices, which implies being open and at the same time sensitive to the objects (Gadamer, 1996). Our prejudices comprise experience and knowledge of intensive care as professional carers, teachers and researchers. Moreover, knowledge from previous research and our view of the human being and caring influenced our interpretation.
Settings and participants Data were collected from a university hospital in Sweden with a regional referral area covering approximately 1.5 million inhabitants. The ICU has 12 beds and admits adult patients with medical and surgical conditions and trauma. The 10 patients (six men and four women) included in the study met the following criteria: ≥18 years old, acute admission due to critical illness/serious injuries, an ICU stay of ≥48 h, mechanically ventilated for ≥24 h, and at least one visit from a next of kin (n = 24). Patients with head injuries, psychiatric diagnoses and intoxication were excluded. The inclusion criteria were intended to ensure a representative data set that allowed a rich description and opportunities for a follow-up interview with both patients and their family members. Six of the visitors were spouses, five were parents, six close friends, two siblings, three children and two grandchildren. The ICU was organised so that the patients were cared for in a two-bed room. One critical care nurse (CCRN) and one enrolled nurse (EN) were responsible for two patients. Visiting was allowed around the clock after agreement with the CCRNs. The staff received verbal and written information about the study. Most of the patients were unconscious or in a condition that prevented them from giving their consent; instead family members gave informed consent on both their own and the patient’s behalf.
Intensive care unit—–An observational hermeneutic study Although some of them were conscious and alert, the medical treatment had blurred their minds. Informed consent from the patients was obtained after the treatment period (Lemaire, 2008). The study was approved by the Research Ethics Committee of the Sahlgrenska Academy, University of Gothenburg (S 012-03).
53
Results The interpretation of the observations is structured and presented under the following three headings; the scene, the actors and the plot. Each section starts with a descriptive text and concludes with the interpretation.
The scene Data collection Non-participant observations were conducted in order to study the interplay between the next of kin and the patient. As a data collection method, observation relates to field research and the natural setting and thus reflects real-life situations. It is important to collect data from and within the natural environment, i.e. in this case to gain access to situations and concepts that occur in the daily life of patients and their next of kin. Wolcott (1995) uses the concept of the privileged observer instead of participant or non-participant observer. A privileged observer is considered to be an individual who is well known and accepted in the unit and who has easy access to the patients’ records, history and circumstances. Therefore the first author, who was involved in education and administration at the unit, but not in handson caring, performed all the observations (Granberg-Axéll et al., 2001; Wolcott, 1995). It was deemed important for the privileged observer to take no notice of the professionals but to focus on the interplay between the patient and his/her relatives, who were observed on one occasion, during which notes were taken. Each observation lasted a maximum of 2 h per day, in order to avoid invading the privacy of those involved. This has been found to be the most common duration of an ICU visit (Eriksson and Bergbom, 2007). The role as the observer was, as described by Gadamer, to metaphorically sit in the audience and be entranced and absorbed by ‘‘the play’’. Edvardsson and Street (2007) stated that when conducting research, the investigator must use his/her senses such as movement, sound, smell, touch and sight to put questions to the play and embody the situation. After each observation session the notes were transcribed together with the observer’s reflections.
Interpretation and analysis The first step of the interpretation process was to organise the text into a script similar to a theatre play. This was achieved by documenting ‘‘the play’’ and writing down the context or physical environment in which the visit and interplay took place. The original text was complemented by notes about what occurred between the actors, i.e. visitors and patient, in each observation. In a final step, the observer’s reflections on the notes made after the observations were written down in a parallel column of the text. The next part of the process was to start questioning the text. What characters were present, what roles did they play and who had the leading role(s)? What was the scenery like and what props were used and why? What was the plot and what was the atmosphere like?
The room in which the patients were cared for had two beds. The windows were small and situated on the wall just opposite the entrance door. The two beds were positioned facing the door. There was also a ventilation shaft at the end of each bed. The beds were separated by curtains made of synthetic non-transparent white fabric, which were the only things that provided the patients and their next of kin with some privacy. Next to the bed was a device containing the ventilator and observation monitors; there was also some suction equipment as well as items for oral care. There was no space around the bed for the patient’s personal belongings. At the end of the bed there was a cabinet on wheels where the observation list as well as some bed linen was kept. Just beside the door were a desk and a cupboard for the storage and preparation of drugs. There was also a computer logged on to the hospital system that was used for documentation and information retrieval. The utility room was situated at the other side of the door. All the doors had a small circular window, like a porthole on a boat. A few of the patients had flowers beside their beds in addition to get-well cards from their relatives and friends, some soft toy animals and photos of themselves when they were healthy; i.e. before the incident that brought them to ICU. However, most of the patients in this study had no personal possessions in the room. During the interpretation process we put questions to the text such as—–what meaning does an impersonal and technical physical environment have for the interplay?’ It became obvious that the design of the stage did not support interplay between the patient and his/her family. There was limited space for the patient’s personal belongings. The noise of the ventilator was a loud, mechanical, tapping sound like a heart beat. This sound could be interpreted as providing security but certainly in some cases insecurity. The room was ‘‘breathing’’, which means that it was primarily designed for the staff and characterised by a medical and technical perspective. The atmosphere was dominated by a rational view, a working environment designed for the staff rather than the patient. There was space for nurses and physicians but no room for visitors. Why were the beds facing the doors? Was it because it offered a more convenient environment for the staff by allowing them a good view of the patients? Or was it impossible and unsafe to turn the beds, thus letting the patients have a view of the window? Looking at two round portholes may have given the patient the impression of being on a boat. The environment was neither welcoming nor caring. However, in the interpretation, it became very clear that there were large differences in the atmosphere between the various scenes that took place in the room. This was interpreted as due to the attitude of the professionals and the way in which they encountered the patient
54 and their next of kin. In one of the rooms the professionals created a caring and welcoming atmosphere, whereas in another room the caring seemed to take place in an unwelcoming atmosphere. We did not conduct any deeper analysis of this situation, as the professionals were not in focus. Both the patient and the next of kin played an important role in the creation of a caring atmosphere.
The actors In most of the scenes the leading actor was the patient, who was confined to bed. Therefore two themes were identified, namely the unreachable patient and the reachable patient. The theme the unreachable patient was divided into two sub-themes, the unconscious patient and the conscious patient. The latter was often so confused that his/her behavior became the focus of attention, resulting in a lack of interest in his/her personality or the next of kin being unable to interact with him/her. When watching the unconscious patient without any visible form of communication, the next of kin’s attempt at interaction was focused on the patient at all times, even when there was no response. In other scenes the focus was not on the patient at all and he/she seemed to have a walk-on instead of the main part and was a character that the other actors talked about instead of to. It was problematic when patients attempted to gain attention and their next of kin were unable to understand what they were trying to say, as the patients eventually gave up and the interplay ceased. Another form of interplay was mutual understanding, which implies wordless interplay with only eye and body contact. In such situations the patient appeared calm, confident, relaxed and was able to sleep. The reachable patient was alert and calm and there was a hint in the atmosphere that this was because of the way the next of kin talked and moved. This interplay indicated that the patient heard and understood, even when he/she was asleep. The interplay was focused on the patient, although in some cases the patient insisted on being the centre of attention. In such situations, his/her body movements were more coordinated and relevant. The interpretation of the scenes revealed six themes describing the next of kin’s interplay. The first is the peaceful, present and focused next of kin who are there for the patient, which is exemplified by the following scene: the patient’s ex-girlfriend sat bedside him holding his hand, looking into his eyes and communicating without words. The patient’s mother, who was also present, described this as supernatural. She stated that having witnessed this very special interplay between the young woman and her son, she was unable to understand how they could generate such magic. She felt safe and secure with the ex-girlfriend acting as interpreter and communicator. The second theme is the sorrowing and grieving next of kin who dissociate themselves from the patient. They seem to be at the start of the shock phase and unable to cope with the situation. One of the patients was an older man who had undergone acute abdominal surgery. His wife was on her daily visit together with a grandchild. It was the grandchild’s first visit. The granddaughter was so shocked that she was unable to interact with her grandfather at all. But her grandmother helped her and at the end of the visit she wiped her
T. Eriksson et al. grandfather’s mouth with a wet cloth and sang songs for him with her grandmother. The third theme is the next of kin who are inquisitive and search for facts, which implies a tendency to dissociate themselves from the patient and hide behind the technical data and equipment. One example was the questioning and very technically minded father of a young man who was unconscious. His mother was sitting close to the bed, talking to him and caressing his face and hand. There was little dialogue between the parents, but the father asked the nurses many questions about the graphs and figures on the monitors. He never talked about or spoke to his son and kept walking around the room as far as possible from the bed. His son was the only patient in the room at that time. On one occasion the mother left the room. Then the father took the mother’s the position and place. He sat close to the patient and talked, caressed him and showed compassion and love. When the mother returned, the father immediately gave her his place. The fourth theme is the confused next of kin who does not understand what has happened, which implies being in the midst of the crisis. There was a young man who was unconscious and on ventilator treatment as a result of having fallen from a tree. His mother was unable to calm down or connect to him. Instead, she was very interested in the patient in the next bed. The only way the staff could get her to pay attention to her son was to ask her to massage his hands and feet with a skin lotion. During that process she became calmer and was able to connect and interact with her son. In this example the nurse guided her by suggesting an effective way of connecting to her son through touch. The fifth theme is the quiet and protective next of kin who watch over the patient. One man visited his wife who had undergone acute abdominal surgery, after which many medical complications had occurred. The couple both used wheelchairs and their personal assistant was present in the room during the visit. The room was in complete silence; there was no form of verbal or non-verbal interplay between the assistant and the husband. He was holding his wife’s hand but was totally mute. The nurse started a dialysis machine. The sixth and final theme is the capable next of kin, who demonstrate their experience of such situations. These next of kin act as professional carers but create a closer relationship, i.e. a naturally caring situation. A man who had undergone a transplant was visited by his brother. The patient had just been extubated and was very confused. He wanted to go home and tried to pull away all the tubes and wires and get out of bed. His brother had such great patience. He talked about things they had done before the hospital admission and how lovely the nurses were. He tried to connect his brother to the present. This comforted the patient, made him calm down and fall asleep. Although the professionals were not in focus in this study, they were always present and had a minor role in the interplay.
The plot In order to gain a deep understanding of the text, the next step focused on revealing the main plot in the scenes, which was interpreted as a changed understanding of the meaning of life, as the event happened without any warning. All the actors had different backgrounds, knowledge and
Intensive care unit—–An observational hermeneutic study experiences that affected them when living through this lifechanging event. The scenes focused on the patient, who had the leading role. However, parts of the scenes highlighted the relatives. In these situations the patient was like a person with a walk-on part in the play. There were also tragicomic situations that were very warm and full of laughter, despite occurring in the midst of a life-changing event. However, the plot was also characterised by frustration. The patients were frustrated because no one understood them, while the relatives were frustrated because they were unable to understand what the patient was trying to say. The scene thus contained a lack of communication and a great deal of misunderstanding. The environment constituted an obstacle and metaphorically the whole atmosphere breathed technological treatment. This leads to a risk of professionals devoting their attention to technology, which to some extent hinders them from listening to patients and next of kin. The understanding of the plot concerns people who had entered a situation where normal everyday life was disconnected. The path from health to illness was a totally unfamiliar environment and perception of life, where the body constituted a new and unknown world. Due to a medical condition the patients were unable to use their bodies normally, which transmitted unknown signals to the next of kin, who in turn experienced difficulty knowing how to respond. Both parties were trapped or locked out by their own body.
Discussion In everyday life we take the body for granted. It is the embodiment of who we are. The self becomes what it is through body and in that way the body is the self’s representative in the world (Merleau-Ponty, 1999). The body speaks to the person through sensations, which brings meaning to us in the social world (Corbin, 2003). As a result of treatment and the seriousness of the illness, the ICU patient’s body sends signals that the next of kin neither recognise nor understand. This situation ends in a scene where the patients and relatives become disconnected and unable to interplay. There are evidence-based sedation protocols aimed at reducing morbidity, mortality and duration of mechanical ventilation in addition to the length of stay in the ICU. These protocols combine daily spontaneous awakening and breathing trials with regimes where the patient is less sedated but analgesic (Girard et al., 2008). Such regimens keep the patient free from pain while ensuring that he/she is more alert and able to understand the often strange sensations transmitted by his/her body. The various ways in which the relatives took part in the interplay demonstrate that there are many forms of reaction to a threatening and life-changing event. Some of their reactions obstructed the connection with the patient, although most of them were able to connect. Earlier studies (Eggenberger and Nelms, 2007; Engström and Söderberg, 2007; Williams, 2005) have described similar reactions. In the actual setting, the interior and exterior architecture did not promote caring and welcoming encounters. This was to a great extent caused by the technical devices
55 that took up a great deal of space in the room. Unfortunately this equipment prevented the relatives from being close to the bed without interfering with all the unfamiliar machines. The fear of accidentally touching something that was connected to their loved one was overwhelming and obstructed the interplay. Almerud et al. (2007) claim that technical devices in the ICU have a negative impact on health care professionals, as they do not pay attention to the patients. Staff may view the patient’s physical body as a measurable object. All eyes, even those of the relatives, turn to the technical equipment as opposed to the patient. It is therefore vital that nursing practice and education highlight and reflect on these problems and how to solve them. Research on how to create a caring and healing environment is ongoing, especially in the United States of America, which is at the forefront of this area (Rashid, 2007; Ulrich et al., 2008). A trend in healthcare design today is single-bed rooms with accommodation for the family. Such rooms reduce infections, noise and medical errors as well as enhancing communication. A room with a view, especially of a landscape, garden or forest, is beneficial for the healing process (Ananth, 2008; McCarthy, 2004). The interior design and environment can cause or worsen delirium or delusional memories in the patient (Dijkstra et al., 2006). The concept geography of nursing has its roots in Nightingale’s Notes on Nursing published in 1860, which considered the importance of health care settings (Andrews, 2003). The focus in geographical research is on place as well as space related to health and wellness, in addition to medicine and disease (Andrews, 2003, p. 243). We have not focused on the professionals but there are studies that reveal differences in the way the professionals perceive and meet the needs of the relatives (Engström and Söderberg, 2007; Söderström et al., 2006; Takman and Severinsson, 2005; Williams, 2005). What can we learn from the scenes that encompassed caring and a caring response? The body seems to play a key role in allowing us to connect by means of natural care. When interpreting the scenes we found differences in the atmosphere of the room. To create a healing atmosphere, the professionals must help the next of kin to find a way to provide natural care in the same way as they did in ordinary life, i.e. before the patient was admitted to the ICU. A healing atmosphere is created when both professionals and relatives perform natural caring. In this context, the word natural means spontaneous, similar to spontaneous charity that assumes responsibility for the other without compulsion or ulterior motives (Løgstrup, 1994). Charity and compassion are spontaneous modes of being but the slightest reduction of their original purpose completely ruins charity and transforms it into mercilessness. Compassion is a natural way of being and begins from the very moment the nurses share the patient’s and relatives’ suffering. Spontaneous compassion means that the nurses and relatives do something out of consideration for the patient’s condition and needs, without any wish for personal gain (Eriksson, 1997; Løgstrup, 1994).
Critiques of the method Non-participant observations were considered an appropriate data collection method. There are different ways
56 of performing an interpretation. Why did we choose to approach the data as a theatre play? In qualitative research, the data invite the researcher to follow the meaning. It struck us that the situation in the ICU room was similar to what Gadamer means when stating that hermeneutic understanding can be viewed as a work of art and/or play. The rooms were small, with little space for an extra person, which sometimes resulted in problems finding a place that did not hinder the interplay. Williams (2005) claims that video recording in combination with observations is a good method for understanding the visiting situation of families in an ICU. We considered using video recording, but at that time it was difficult to obtain ethical approval. The reason given was the need to protect personal integrity. The total duration of the observations was 20 h. Ten patients took part and a total of 24 next of kin were present during the observations, which can be considered too small sample. Conducting research in an ICU can be problematic. One aspect is the difficulty gaining access to the patients, as they are vulnerable and need to have their personal integrity protected. The length of the observation sessions had to be handled with great care. However, the content of the data was found to be appropriate for a sound analysis. One can criticise the researchers for doing fieldwork in their own workplace. Gadamer claims that prejudices have their own importance in the interpretation of a text, as they form the basis of our understanding of tradition (Palmer, 1969). Being a privileged observer means being placed in the tradition of ICU care. However, there is always a risk of being unable to control one’s prejudices. For this reason the manuscript has been refined by means of discussions and critical reflections among the authors. Critical peer review of the study was also obtained at a research seminar.
Conclusion When a sense of togetherness was lacking in the room, it affected the interplay between the patients and relatives. In situations where there was more than one relative present, the inability to connect also influenced the relationship between the relatives. The professionals are crucial for interpreting the signals from both patient and next of kin and for finding caring strategies that facilitate interplay, which in turn supports connectedness. Physical contact as in natural care was one such strategy. A hindrance to the interplay was the fact that the room was designed for medical and technical use, an environment that does not promote healing. We consider the observational method and hermeneutic analysis used in this study to be fruitful in the ICU context.
Conflict of interest The authors have no conflicts of interest.
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available at www.sciencedirect.com
journal homepage: www.elsevier.com/iccn
ORIGINAL ARTICLE
Visits in an intensive care unit—–An observational hermeneutic study Thomas Eriksson a,b,∗, Berit Lindahl c,d, Ingegerd Bergbom c a
CIVA/96, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Sweden c Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Box 457, SE-405 30 Göteborg, Sweden d School of Health Sciences, University College of Borås, Allégatan 1, SE-501 90 Borås, Sweden b
Accepted 24 September 2009
KEYWORDS Hermeneutics; Observations; Visitors to patients; Critical care
Summary Aim: The aim was to interpret the interplay between critically ill patients and their next of kin in an ICU and to disclose a deeper understanding of the visiting situation. Method: A hermeneutic research design with non-participant observation was chosen as the data collection method. Ten observations of 10 patients and 24 loved ones over a 20-h period were conducted. The text describing the observations of the interplay was interpreted in accordance with Gadamer’s thoughts. Data were analysed by considering the text as a play with scenes, actors and plots. Findings: Due to their medical condition the patients were unable to use their bodies in the usual way, which sends different signals to their loved ones, who in turn have difficulty deciding how to respond. Both parties become, in a manner of speaking, trapped or locked out by their own bodies. Conclusion: The physical environment became a hindrance to the interplay as it was designed for medical and technical use and thus did not promote healing. The professionals are important for interpreting the signals from both patients and next of kin, as well as for finding caring strategies, such as physical contact that promote interplay, which in turn strengthens connectedness. © 2009 Elsevier Ltd. All rights reserved.
Introduction ∗
Corresponding author at: CIVA/96, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden. Tel.: +46 31 342 16 84; fax: +46 31 41 44 83. E-mail addresses: [email protected] (T. Eriksson), [email protected] (B. Lindahl), [email protected] (I. Bergbom).
The patient is the most important person in intensive and critical care. He/she is ‘‘the suffering person’’; the one cared for and at whom the care is aimed. The patient’s world stands out as suffering (Eriksson, 1997). It is evident that loved ones are an important source of support for critically ill patients (Magarey and McCutcheon, 2005). In
0964-3397/$ — see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.iccn.2009.09.005
52 several international studies (Bergbom and Askvall, 2000; Eggenberger and Nelms, 2007; Engström and Söderberg, 2007; Ringdal et al., 2008; Storli et al., 2008; Williams, 2005), patients have stated that loved ones are vital because they motivate the patient to stay alive and continue the struggle for survival. Thus, the presence of loved ones is essential for the patient and must be encouraged by the nurses. An earlier study elucidated the extent to which patients have visitors. It was found that about 25% of patients did not have any visitors at all during their intensive care unit (ICU) stay. However, those patients were older and often lived alone (Eriksson and Bergbom, 2007). The number of such patients is increasing in ICUs today, and it seems logical to conclude that nurses have to care for a higher percentage of patients with no loved ones and/or visitors. In an interview study, Söderström et al. (2006) found that the initial interaction with the staff had a significant effect on family members and influenced not only their future relationship with the professionals, but also their ability to care for and motivate the patient. Mutual understanding and misunderstanding were two aspects of the interaction between family members and staff. Support from staff members enabled next of kin to use both internal and external resources to cope with having a loved one in the ICU. Having trust in themselves as well as encountering professionalism and charity gave the next of kin a sense of empowerment (Johansson et al., 2005). An interview study by Ågård and Harder (2007) revealed that the next of kin tried to manage a chaotic and frightening situation by attempting ‘‘to fit in’’. The issue of the presence and influence of patients’ next of kin in the ICU is an important and complex topic among ICU staff. There is consensus in the literature that visits by next of kin are beneficial for the patient and his/her family, but visiting procedures/routines vary between hospitals as well as countries (Latour, 2005). The large variation may be due to lack of compliance with scientific evidence as well as the current cost-cutting climate, which can result in a heavy workload and less time being devoted to the patients and their next of kin (Endacott and Berry, 2007). Another problem is that lack of nursing and medical staff leads to less time spent ‘‘caring’’ for the relatives, and nurses are neither trained nor prepared for such a relationship (Price, 2004; Williams, 2005). It is therefore of interest to obtain knowledge about caring in the interplay between patients and their next of kin in order to develop alternative forms of care and new strategies, i.e. what can we learn about caring from family members’ relationship and interplay when one of them is critically ill/injured? The professional and caring perspective in this study regards the human being as a whole, a unity of body, soul and spirit. Caring is natural and primordial and motivated by love and concern for fellow human beings.
Aim The aim was to interpret the interplay between critically ill patients and their next of kin in an ICU and to disclose a deeper understanding of the visiting situation.
T. Eriksson et al.
Method A hermeneutic method was used in this study. Hermeneutics is the classic discipline that deals with the art of trying to understand texts and attempts to reflect the humanistic, scientific way of understanding human beings’ cultural activities, i.e. relationships with other human beings (Gadamer, 1996). Texts are interpreted in order to grasp their meaning and thereby gain understanding with a view to traditions so that the historic dialogue of mankind can continue and become deeper (Helenius, 1990; Polit et al., 2001). A complex and nuanced world cannot be explained in exact terms, but only understood broadly (Eriksson, 1997). Both Gadamer (1996) and Løgstrup (1994) describe texts as a dimension of art; text creates a scene, which allows us to observe from the outside in the same way as a theatre play. This statement was the reason for the analysis process used in the present study. Gadamer (1996) talks about games and plays that bewitch, entrance and absorb so that one apprehends them as reality. This implies that one becomes a part of the game and what is fascinating is that the play governs the player (Selander and Ödman, 2004). A hermeneutic study implies that the interpretation and understanding of the data are based on the researcher’s existing knowledge and experience of the subject under investigation, i.e. prejudices. The role of the interpreter is to bring together the horizons of the past and present, i.e. a fusion of horizons. It is thus important that the researcher is aware of his/her own prejudices, which implies being open and at the same time sensitive to the objects (Gadamer, 1996). Our prejudices comprise experience and knowledge of intensive care as professional carers, teachers and researchers. Moreover, knowledge from previous research and our view of the human being and caring influenced our interpretation.
Settings and participants Data were collected from a university hospital in Sweden with a regional referral area covering approximately 1.5 million inhabitants. The ICU has 12 beds and admits adult patients with medical and surgical conditions and trauma. The 10 patients (six men and four women) included in the study met the following criteria: ≥18 years old, acute admission due to critical illness/serious injuries, an ICU stay of ≥48 h, mechanically ventilated for ≥24 h, and at least one visit from a next of kin (n = 24). Patients with head injuries, psychiatric diagnoses and intoxication were excluded. The inclusion criteria were intended to ensure a representative data set that allowed a rich description and opportunities for a follow-up interview with both patients and their family members. Six of the visitors were spouses, five were parents, six close friends, two siblings, three children and two grandchildren. The ICU was organised so that the patients were cared for in a two-bed room. One critical care nurse (CCRN) and one enrolled nurse (EN) were responsible for two patients. Visiting was allowed around the clock after agreement with the CCRNs. The staff received verbal and written information about the study. Most of the patients were unconscious or in a condition that prevented them from giving their consent; instead family members gave informed consent on both their own and the patient’s behalf.
Intensive care unit—–An observational hermeneutic study Although some of them were conscious and alert, the medical treatment had blurred their minds. Informed consent from the patients was obtained after the treatment period (Lemaire, 2008). The study was approved by the Research Ethics Committee of the Sahlgrenska Academy, University of Gothenburg (S 012-03).
53
Results The interpretation of the observations is structured and presented under the following three headings; the scene, the actors and the plot. Each section starts with a descriptive text and concludes with the interpretation.
The scene Data collection Non-participant observations were conducted in order to study the interplay between the next of kin and the patient. As a data collection method, observation relates to field research and the natural setting and thus reflects real-life situations. It is important to collect data from and within the natural environment, i.e. in this case to gain access to situations and concepts that occur in the daily life of patients and their next of kin. Wolcott (1995) uses the concept of the privileged observer instead of participant or non-participant observer. A privileged observer is considered to be an individual who is well known and accepted in the unit and who has easy access to the patients’ records, history and circumstances. Therefore the first author, who was involved in education and administration at the unit, but not in handson caring, performed all the observations (Granberg-Axéll et al., 2001; Wolcott, 1995). It was deemed important for the privileged observer to take no notice of the professionals but to focus on the interplay between the patient and his/her relatives, who were observed on one occasion, during which notes were taken. Each observation lasted a maximum of 2 h per day, in order to avoid invading the privacy of those involved. This has been found to be the most common duration of an ICU visit (Eriksson and Bergbom, 2007). The role as the observer was, as described by Gadamer, to metaphorically sit in the audience and be entranced and absorbed by ‘‘the play’’. Edvardsson and Street (2007) stated that when conducting research, the investigator must use his/her senses such as movement, sound, smell, touch and sight to put questions to the play and embody the situation. After each observation session the notes were transcribed together with the observer’s reflections.
Interpretation and analysis The first step of the interpretation process was to organise the text into a script similar to a theatre play. This was achieved by documenting ‘‘the play’’ and writing down the context or physical environment in which the visit and interplay took place. The original text was complemented by notes about what occurred between the actors, i.e. visitors and patient, in each observation. In a final step, the observer’s reflections on the notes made after the observations were written down in a parallel column of the text. The next part of the process was to start questioning the text. What characters were present, what roles did they play and who had the leading role(s)? What was the scenery like and what props were used and why? What was the plot and what was the atmosphere like?
The room in which the patients were cared for had two beds. The windows were small and situated on the wall just opposite the entrance door. The two beds were positioned facing the door. There was also a ventilation shaft at the end of each bed. The beds were separated by curtains made of synthetic non-transparent white fabric, which were the only things that provided the patients and their next of kin with some privacy. Next to the bed was a device containing the ventilator and observation monitors; there was also some suction equipment as well as items for oral care. There was no space around the bed for the patient’s personal belongings. At the end of the bed there was a cabinet on wheels where the observation list as well as some bed linen was kept. Just beside the door were a desk and a cupboard for the storage and preparation of drugs. There was also a computer logged on to the hospital system that was used for documentation and information retrieval. The utility room was situated at the other side of the door. All the doors had a small circular window, like a porthole on a boat. A few of the patients had flowers beside their beds in addition to get-well cards from their relatives and friends, some soft toy animals and photos of themselves when they were healthy; i.e. before the incident that brought them to ICU. However, most of the patients in this study had no personal possessions in the room. During the interpretation process we put questions to the text such as—–what meaning does an impersonal and technical physical environment have for the interplay?’ It became obvious that the design of the stage did not support interplay between the patient and his/her family. There was limited space for the patient’s personal belongings. The noise of the ventilator was a loud, mechanical, tapping sound like a heart beat. This sound could be interpreted as providing security but certainly in some cases insecurity. The room was ‘‘breathing’’, which means that it was primarily designed for the staff and characterised by a medical and technical perspective. The atmosphere was dominated by a rational view, a working environment designed for the staff rather than the patient. There was space for nurses and physicians but no room for visitors. Why were the beds facing the doors? Was it because it offered a more convenient environment for the staff by allowing them a good view of the patients? Or was it impossible and unsafe to turn the beds, thus letting the patients have a view of the window? Looking at two round portholes may have given the patient the impression of being on a boat. The environment was neither welcoming nor caring. However, in the interpretation, it became very clear that there were large differences in the atmosphere between the various scenes that took place in the room. This was interpreted as due to the attitude of the professionals and the way in which they encountered the patient
54 and their next of kin. In one of the rooms the professionals created a caring and welcoming atmosphere, whereas in another room the caring seemed to take place in an unwelcoming atmosphere. We did not conduct any deeper analysis of this situation, as the professionals were not in focus. Both the patient and the next of kin played an important role in the creation of a caring atmosphere.
The actors In most of the scenes the leading actor was the patient, who was confined to bed. Therefore two themes were identified, namely the unreachable patient and the reachable patient. The theme the unreachable patient was divided into two sub-themes, the unconscious patient and the conscious patient. The latter was often so confused that his/her behavior became the focus of attention, resulting in a lack of interest in his/her personality or the next of kin being unable to interact with him/her. When watching the unconscious patient without any visible form of communication, the next of kin’s attempt at interaction was focused on the patient at all times, even when there was no response. In other scenes the focus was not on the patient at all and he/she seemed to have a walk-on instead of the main part and was a character that the other actors talked about instead of to. It was problematic when patients attempted to gain attention and their next of kin were unable to understand what they were trying to say, as the patients eventually gave up and the interplay ceased. Another form of interplay was mutual understanding, which implies wordless interplay with only eye and body contact. In such situations the patient appeared calm, confident, relaxed and was able to sleep. The reachable patient was alert and calm and there was a hint in the atmosphere that this was because of the way the next of kin talked and moved. This interplay indicated that the patient heard and understood, even when he/she was asleep. The interplay was focused on the patient, although in some cases the patient insisted on being the centre of attention. In such situations, his/her body movements were more coordinated and relevant. The interpretation of the scenes revealed six themes describing the next of kin’s interplay. The first is the peaceful, present and focused next of kin who are there for the patient, which is exemplified by the following scene: the patient’s ex-girlfriend sat bedside him holding his hand, looking into his eyes and communicating without words. The patient’s mother, who was also present, described this as supernatural. She stated that having witnessed this very special interplay between the young woman and her son, she was unable to understand how they could generate such magic. She felt safe and secure with the ex-girlfriend acting as interpreter and communicator. The second theme is the sorrowing and grieving next of kin who dissociate themselves from the patient. They seem to be at the start of the shock phase and unable to cope with the situation. One of the patients was an older man who had undergone acute abdominal surgery. His wife was on her daily visit together with a grandchild. It was the grandchild’s first visit. The granddaughter was so shocked that she was unable to interact with her grandfather at all. But her grandmother helped her and at the end of the visit she wiped her
T. Eriksson et al. grandfather’s mouth with a wet cloth and sang songs for him with her grandmother. The third theme is the next of kin who are inquisitive and search for facts, which implies a tendency to dissociate themselves from the patient and hide behind the technical data and equipment. One example was the questioning and very technically minded father of a young man who was unconscious. His mother was sitting close to the bed, talking to him and caressing his face and hand. There was little dialogue between the parents, but the father asked the nurses many questions about the graphs and figures on the monitors. He never talked about or spoke to his son and kept walking around the room as far as possible from the bed. His son was the only patient in the room at that time. On one occasion the mother left the room. Then the father took the mother’s the position and place. He sat close to the patient and talked, caressed him and showed compassion and love. When the mother returned, the father immediately gave her his place. The fourth theme is the confused next of kin who does not understand what has happened, which implies being in the midst of the crisis. There was a young man who was unconscious and on ventilator treatment as a result of having fallen from a tree. His mother was unable to calm down or connect to him. Instead, she was very interested in the patient in the next bed. The only way the staff could get her to pay attention to her son was to ask her to massage his hands and feet with a skin lotion. During that process she became calmer and was able to connect and interact with her son. In this example the nurse guided her by suggesting an effective way of connecting to her son through touch. The fifth theme is the quiet and protective next of kin who watch over the patient. One man visited his wife who had undergone acute abdominal surgery, after which many medical complications had occurred. The couple both used wheelchairs and their personal assistant was present in the room during the visit. The room was in complete silence; there was no form of verbal or non-verbal interplay between the assistant and the husband. He was holding his wife’s hand but was totally mute. The nurse started a dialysis machine. The sixth and final theme is the capable next of kin, who demonstrate their experience of such situations. These next of kin act as professional carers but create a closer relationship, i.e. a naturally caring situation. A man who had undergone a transplant was visited by his brother. The patient had just been extubated and was very confused. He wanted to go home and tried to pull away all the tubes and wires and get out of bed. His brother had such great patience. He talked about things they had done before the hospital admission and how lovely the nurses were. He tried to connect his brother to the present. This comforted the patient, made him calm down and fall asleep. Although the professionals were not in focus in this study, they were always present and had a minor role in the interplay.
The plot In order to gain a deep understanding of the text, the next step focused on revealing the main plot in the scenes, which was interpreted as a changed understanding of the meaning of life, as the event happened without any warning. All the actors had different backgrounds, knowledge and
Intensive care unit—–An observational hermeneutic study experiences that affected them when living through this lifechanging event. The scenes focused on the patient, who had the leading role. However, parts of the scenes highlighted the relatives. In these situations the patient was like a person with a walk-on part in the play. There were also tragicomic situations that were very warm and full of laughter, despite occurring in the midst of a life-changing event. However, the plot was also characterised by frustration. The patients were frustrated because no one understood them, while the relatives were frustrated because they were unable to understand what the patient was trying to say. The scene thus contained a lack of communication and a great deal of misunderstanding. The environment constituted an obstacle and metaphorically the whole atmosphere breathed technological treatment. This leads to a risk of professionals devoting their attention to technology, which to some extent hinders them from listening to patients and next of kin. The understanding of the plot concerns people who had entered a situation where normal everyday life was disconnected. The path from health to illness was a totally unfamiliar environment and perception of life, where the body constituted a new and unknown world. Due to a medical condition the patients were unable to use their bodies normally, which transmitted unknown signals to the next of kin, who in turn experienced difficulty knowing how to respond. Both parties were trapped or locked out by their own body.
Discussion In everyday life we take the body for granted. It is the embodiment of who we are. The self becomes what it is through body and in that way the body is the self’s representative in the world (Merleau-Ponty, 1999). The body speaks to the person through sensations, which brings meaning to us in the social world (Corbin, 2003). As a result of treatment and the seriousness of the illness, the ICU patient’s body sends signals that the next of kin neither recognise nor understand. This situation ends in a scene where the patients and relatives become disconnected and unable to interplay. There are evidence-based sedation protocols aimed at reducing morbidity, mortality and duration of mechanical ventilation in addition to the length of stay in the ICU. These protocols combine daily spontaneous awakening and breathing trials with regimes where the patient is less sedated but analgesic (Girard et al., 2008). Such regimens keep the patient free from pain while ensuring that he/she is more alert and able to understand the often strange sensations transmitted by his/her body. The various ways in which the relatives took part in the interplay demonstrate that there are many forms of reaction to a threatening and life-changing event. Some of their reactions obstructed the connection with the patient, although most of them were able to connect. Earlier studies (Eggenberger and Nelms, 2007; Engström and Söderberg, 2007; Williams, 2005) have described similar reactions. In the actual setting, the interior and exterior architecture did not promote caring and welcoming encounters. This was to a great extent caused by the technical devices
55 that took up a great deal of space in the room. Unfortunately this equipment prevented the relatives from being close to the bed without interfering with all the unfamiliar machines. The fear of accidentally touching something that was connected to their loved one was overwhelming and obstructed the interplay. Almerud et al. (2007) claim that technical devices in the ICU have a negative impact on health care professionals, as they do not pay attention to the patients. Staff may view the patient’s physical body as a measurable object. All eyes, even those of the relatives, turn to the technical equipment as opposed to the patient. It is therefore vital that nursing practice and education highlight and reflect on these problems and how to solve them. Research on how to create a caring and healing environment is ongoing, especially in the United States of America, which is at the forefront of this area (Rashid, 2007; Ulrich et al., 2008). A trend in healthcare design today is single-bed rooms with accommodation for the family. Such rooms reduce infections, noise and medical errors as well as enhancing communication. A room with a view, especially of a landscape, garden or forest, is beneficial for the healing process (Ananth, 2008; McCarthy, 2004). The interior design and environment can cause or worsen delirium or delusional memories in the patient (Dijkstra et al., 2006). The concept geography of nursing has its roots in Nightingale’s Notes on Nursing published in 1860, which considered the importance of health care settings (Andrews, 2003). The focus in geographical research is on place as well as space related to health and wellness, in addition to medicine and disease (Andrews, 2003, p. 243). We have not focused on the professionals but there are studies that reveal differences in the way the professionals perceive and meet the needs of the relatives (Engström and Söderberg, 2007; Söderström et al., 2006; Takman and Severinsson, 2005; Williams, 2005). What can we learn from the scenes that encompassed caring and a caring response? The body seems to play a key role in allowing us to connect by means of natural care. When interpreting the scenes we found differences in the atmosphere of the room. To create a healing atmosphere, the professionals must help the next of kin to find a way to provide natural care in the same way as they did in ordinary life, i.e. before the patient was admitted to the ICU. A healing atmosphere is created when both professionals and relatives perform natural caring. In this context, the word natural means spontaneous, similar to spontaneous charity that assumes responsibility for the other without compulsion or ulterior motives (Løgstrup, 1994). Charity and compassion are spontaneous modes of being but the slightest reduction of their original purpose completely ruins charity and transforms it into mercilessness. Compassion is a natural way of being and begins from the very moment the nurses share the patient’s and relatives’ suffering. Spontaneous compassion means that the nurses and relatives do something out of consideration for the patient’s condition and needs, without any wish for personal gain (Eriksson, 1997; Løgstrup, 1994).
Critiques of the method Non-participant observations were considered an appropriate data collection method. There are different ways
56 of performing an interpretation. Why did we choose to approach the data as a theatre play? In qualitative research, the data invite the researcher to follow the meaning. It struck us that the situation in the ICU room was similar to what Gadamer means when stating that hermeneutic understanding can be viewed as a work of art and/or play. The rooms were small, with little space for an extra person, which sometimes resulted in problems finding a place that did not hinder the interplay. Williams (2005) claims that video recording in combination with observations is a good method for understanding the visiting situation of families in an ICU. We considered using video recording, but at that time it was difficult to obtain ethical approval. The reason given was the need to protect personal integrity. The total duration of the observations was 20 h. Ten patients took part and a total of 24 next of kin were present during the observations, which can be considered too small sample. Conducting research in an ICU can be problematic. One aspect is the difficulty gaining access to the patients, as they are vulnerable and need to have their personal integrity protected. The length of the observation sessions had to be handled with great care. However, the content of the data was found to be appropriate for a sound analysis. One can criticise the researchers for doing fieldwork in their own workplace. Gadamer claims that prejudices have their own importance in the interpretation of a text, as they form the basis of our understanding of tradition (Palmer, 1969). Being a privileged observer means being placed in the tradition of ICU care. However, there is always a risk of being unable to control one’s prejudices. For this reason the manuscript has been refined by means of discussions and critical reflections among the authors. Critical peer review of the study was also obtained at a research seminar.
Conclusion When a sense of togetherness was lacking in the room, it affected the interplay between the patients and relatives. In situations where there was more than one relative present, the inability to connect also influenced the relationship between the relatives. The professionals are crucial for interpreting the signals from both patient and next of kin and for finding caring strategies that facilitate interplay, which in turn supports connectedness. Physical contact as in natural care was one such strategy. A hindrance to the interplay was the fact that the room was designed for medical and technical use, an environment that does not promote healing. We consider the observational method and hermeneutic analysis used in this study to be fruitful in the ICU context.
Conflict of interest The authors have no conflicts of interest.
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