An exploratory study of patients' memory recall of their stay in an adult intensive therapy unit

Anne Green

Anne Green BSc(Hons), DipN, RGN, Practitioner Lecturer in Advanced Clinical Skills, Memorial Hospital, Darling*on NHS Trust, Hollyhurst Road, Darling*on, County Durham DL6 9HX, UK

(Requests foroffprintstoAG) Manuscriptaccepted 7March 1996

This study carried forward an exploration to determine if there is a need to visit patients in a ward following discharge from an adult intensive therapy unit (ITU), by ascertaining what patients remember of their stay and their ability to cope with this experience.

Data were collected during interviews 48 hours following subjects' discharge from the ITU, and collated using an adaptation of thematic content analysis as described by Burnard (1991). Twenty- six subjects were studied over a 6-month period.

The findings suggest that patients have vivid recollections of their stay in an ITU, and are consistent with previous research in respect of patients continuing to experience dreams, pain, sleep deprivation and worries about transfer out of an ITU to a ward.

New themes suggest that ITU patients do not recall their 'named nurse', but do recall detailed explanations given to them by nurses in the ITU. Patients also believe they would benefit from a follow- up visit to discuss and clarify aspects of their stay which were unclear or are causing them concern.

I N T R O D U C T I O N

The intensive therapy unit (ITU) environment has been noted as being twice as likely as other clinical areas to cause psychological distur-

bances (Wilson 1972). This knowledge has promoted the practice of seeing patients in the ward before surgery, once they have been identified as requiring intensive care after it. This study arose from the author's concern that patients who recovered and were discharged from the ITU, where she worked, to a ward received no formal follow-up to discuss feelings about their experience. Nursing care, the out- come of the pre-admission visit and its effect were therefore not being evaluated from the patient's perspective.

LITERATURE REVIEW

Reports of some published studies indicate that patients receiving intensive care have poor recall of their stay. Chew (1986), for example, found that 92% of patients had very few mem- ories of their stay.

Findings of a more recent study contradict this. Puntillo (1990) interviewed 24 surgical ITU patients, from two hospitals, and found that only one patient had no recollection. This raised a fundamental question for the proposed study - do patients actually remember being in ITU?

Other studies have been specific in their enquiry and reported findings suggest that patients are aware of their surroundings, the presence of other people and pain, even when they appear unconscious (Chew 1986, Jones et al 1984).

No studies, however, appear to have addressed whether patients remember anything about the nurses who cared for them during their stay in ITU, and this indicates a gap of knowledge in this area.

This has relevance when placed in the con- text of following and evaluating the Department of Health (1993) guidelines set out in The Vision for the Future document. The Patients' Charter standards (Department of Health, 1991) also state that all patients should be able to identify the name of the nurse who has been responsible for their care. The ability o f patients to recall this information is hence going to be of value in determining whether this standard is in fact measurable, achievable or indeed desirable for patients who have received intensive care.

In respect o f transfer from ITU to a ward, Jones et al (1979) found that 50% of patients were pleased to return to the ward, a transition Donald (1976) recalled with triumph. These studies are, however, in the minority with oth- ers portraying negative feelings about discharge from ITU, reflecting the lack of a nurse's atten- dance at all times in the ward. Some patients

Intensive and Critical Care Nursing (1996) 12, 131-137 © 1996 Pearson Professional Ltd

132 Intensive and Cri t ical Care Nurs ing

have reported feeling neglected and frightened (Clarke 1985) and, more recently, in Norrie's study (1992) feelings of abandonment, alien- ation and insecurity on return to the ward environment were highlighted.

It is evident from this brief literature review that some patients encounter problems associated with their experience in an ITU. The objective of this study was therefore to determine what memories patients had of their stay in the ITU where the author worked (although the author was not working there during the data collection period).

M E T H O D O L O G Y

D e s i g n o f t h e s t u d y

Permission to undertake this study was given by the local district ethics committee. All con- sultants were informed of the study and only one objected to his patients being included. The only constraint stipulated by the ethical committee was that written consent must be obtained from the subjects.

The method of data collection was by focused interviews (Polit & Hungler 1987), whereby a list of questions was used as a topic guide and cues to increase recall, allowing the subject some scope to choose the topic for response and the researcher to follow-up particular responses.

The subjects were recruited according to a convenience sample technique (Dempsey & Dempsey 1992) from all patients who gave writ- ten consent to be included in the study on dis- charge from the designated ITU. This had impli-

Q. 2 Were you aware of the constant care given by any one nurse?

Q. 3 Do you recall being given reassurance and explanations about the care you were being given?

Q. 4 Can you tell me about any dreams you had?

Q. 5 Do you recall being in any pain?

Q. 6 Can you explain to me any sounds or noises that you heard whilst in ITU?

Q. 7 Were you able to sleep?

Q. 8 Could you tell if it was day or night?

Q. 9 Can you explain to me how you felt on being transferred back to the ward?

Q. 10 Have you found this chat useful?

Q. I I Were you visited by an ITU nurse prior to being admitted to the unit? Can you tell me anything about this visit?

Q. 12 I have covered the topics I thought to be applicable to memories you may have had in ITU, is there anything else you would like to add?

The response to Q. I : 'Can you tell me anything about your experience in ITU?' determined the order in which the above questions were asked.

cations for the sample size and also for the conclusions which may be drawn from this study.

A total o f 96 patients were admitted to the ITU over a 6-month period, but only 26 were interviewed. Reasons for not gaining consent included: 28 patients died, 18 patients were too ill to give their written consent when dis- charged from the ITU, 8 patients were trans- ferred to other hospitals within the region, 7 patients were discharged home before they had been interviewed, 3 patients remained in ITU at the close of the study and 1 patient was unable to converse in English.

The remaining 26 patients formed the sam- pie. Nine of these patients (35%) were aged 67-77 years, 7 (27%) aged 44-55 years, 5 (19%) aged 56-66 years, 2 (8%) were 22-32 years and there were 1 each from the 11-21, 33-43 and 78-88 age groups (4%). Fourteen of the sample were male and 12 female.

The majority of patients were admitted following a surgical procedure (42%, 11/26). Sixteen of the sample (62%) required artificial ventilation. Three of these required muscle relaxants resulting in therapeutic paralysis.

Only 5 of the sample were elective admis- sions (19%), 4 of these receiving pre-admission visits. One subject did not receive a visit due to staff being unable to leave the ITU.

The average length o f stay in ITU was 3 days with a range of 1-14 days.

R e s e a r c h t o o l

The interview schedule was constructed using information gained from a literature review and was adapted following a pilot study over a 1- month period and critique for content validity by a nursing colleague in ITU. The schedule was a 3-page document, with the first page for recording biographical details about the sub- ject. The second page gave a brief introduction to, and explanation of, the study for subjects, how their responses would be tape-recorded if they gave permission, and assurance that confi- dentiality would be maintained with respect for their anonymity when reporting findings of the study. The final page listed the questions asked of each subject.

The first question was: 'Can you tell me anything about your experience in ITU?' A subject's initial response to this question dic- tated the order in which the remaining ques- tions were asked (Box). It is acknowledged, with hindsight, that some of the questions put to the patients were leading questions, which may have influenced the responses.

After spending sufficient time with the subjects to explore their experience in detail, but not so long as to tire them, each inter-

Patients' memory recall of their stay in an adult ITU 133

view was concluded and verbal appreciation given to the subject for the use o f his or her time.

The effect of the researcher has been shown to be a possible source of bias in inter- views (Hyman 1954). All the interviews in this study were carried out by the same person therefore maintaining consistency in any bias affecting them. The nurse-patient relationship is also renowned for providing grounds for the halo effect bias described by Rugg (1921). This was overcome to some extent, as the researcher was not working as a member of the team in the I T U during the interviewing process.

The method of thematic content analysis was chosen as a recognised method of analysing qualitative data (Burnard 1991).

RESULTS

Do patients remember being in an ITU?

Study findings demonstrated that only 2 of the 26 subjects had absolutely no recollection of their stay in ITU: a female in the 78-88 years age group, whose stay following formation of an ileostomy had been only 13 hours, and a male aged between 56 and 66 years, whose stay following a cardiac arrest had been 3 days. These subjects had received different medica- tion and only one had been artificially venti- lated, indicating no common variables.

Subjects' unprompted responses to the first question related to uncomfortable or painful experiences (31%, 8/26), followed by the presence of tubes (27%, 7/26), the feeling of panic or fear (23%, 6/26), not knowing where they were and the presence o f relatives (19%, 5/26). Less frequently described were positive comments about nursing staff (8%, 2/26), the subjects' inability to communicate (8%, 2/26), being unable to sleep (4%, 1/26) and thoughts about dying (4%, 1/26).

Do patients having been in an ITU remember the nurses who cared for them?

Study findings demonstrated that nine subjects (35%) were able to remember correctly the names o f nurses who cared for them in ITU; another nine (35%) were unable to recall the names but could correctly describe their nurse, either by appearance, personality or their accent. Six subjects (23%) were unable to remember any of the nurses' names, whereas four (15%) remembered names incorrectly.

The ability to remember the name of the nurse did not appear to be affected by whether the subject had been visited before admission to the ITU. O f the 4 subjects who had been vis- ited by their 'named nurse', none could remember the nurse's name.

Do patients recall receiving reassurance and explanations about their care whilst in an ITU?

When subjects were asked if they could recall any explanations or reassurance they had been given by nurses, only 6 (23%) said they could not remember.

Seven subjects (27%) recalled explanations regarding their treatment, the results of tests and operations or various tubes. Other com- mon explanations related to being told the time of day, being given reassurance and explana- tions during bathing and turning, and that he or she was 'alright'.

Other findings related to communication. Six (23%) expressed their delight that nurses talked to them and not over them, and spoke the truth. However, three subjects recalled overhearing conversations about other patients and assumed the nurses to be discussing their own cases.

Patients' experiences of ITU psychoses

The results of this study are consistent with Schnaper & Cowley (1976) and Chew's (1986) findings, that at least half of the patients receiv- ing intensive care wit1 experience ITU psy- choses. The incidence of disturbance in this study, however, appeared much higher, with 73% (19/26) of the subjects recalling disturbing dreams (although dreams do not necessarily indicate psychosis). The lack of windows in the ITU could be a contributory factor (Keep et al 1980).

Five subjects (19%) were still unsure if their dreams had in fact been reality. Subjects recounted from dreams, for example, waiting at the picture show, experiencing an earthquake, and travelling through the desert on a train.

Ten (38%) subjects recalled having night- mares, occasionally related to the belief that they were dying, causing subjects to feel fright- ened or believe they were going mad.

Consistent with other studies (e.g. Shovelton 1979) some hallucinations related to the environment of the ITU, as one subject explained:

The first impression I got, I couldn't tell you day, time or anything. I opened my eyes and

134 Intensive and Critical Care Nursing

there was this brilliantly lit room, absolutely white bright. It must have been the drugs because there was a shimmer and I was firmly convinced I was underwater. The thought came, 'how did they get me down here', then I drifted off.

The experience of psychological distur- bances continuing after discharge from the I T U was reported by five subjects, which coincides with the findings of Schnaper & Cowley (1976), Ballard (1981) and Benzer et al (1983), where disturbances were reported to continue for up to 48 hours after discharge. Two of the five subjects affected in this study, however, reported hallucinations continuing in the ward for up to 96 hours, and as a result the patients had been unable to sleep and were extremely frightened.

Pain experiences in an ITU

The incidence of pain was recalled by 69% (18/26) of subjects, which is consistent with Puntillo's (1990) finding of 70%. Thirteen (50%) described their pain as tolerable or caus- ing discomfort, whereas eight (31%) recalled intense pain.

The major cause of pain was described as being physiotherapy treatment. An equal pro- portion of subjects receiving alfentanil recalled either being in pain or reported no pain, and this can also be said of those subjects who received intravenous opiates and those who self-administered morphine via a patient controlled analgesia device.

Pain is a very individual experience and is influenced by many factors, one of which is anxiety (Green 1990). Anxiolytics and seda- tives, such as midazolam, Diazemuls and propofol, were administered to 17 patients, and these did not appear to result in memory loss, with 8 subjects recalling their pain experiences compared to 9 who could not.

Noise

Unlike previous studies (Asbury 1985, Clarke 1985, Chew 1986), this study revealed that 65% (13/26) of the subjects believed I T U to be a quiet place.

The commonest noise recalled was the 'beeps' of monitors and other equipment (25%, 5/20). Other noises recalled were mumbling and chatter by nursing staff (15%, 3/20), fol- lowed by noises associated with the ventilator (10%, 2/20). Unlike Henschel (1977) and Chew's (1988) studies, no subjects reported the telephone as a source of noise.

Sleep

While 42% (11/26) of subjects reported being unable to sleep, seven of those who said they had been able to sleep reported that they had just drifted 'on and off' into sleep.

Previous studies have attributed the inabil- ity to sleep to such factors as noise, being in pain and disorientation to day and night time. In this study only two of the subjects unable to sleep reported the unit to be noisy, how- ever approximately half the sample recalled being in pain and unable to distinguish between day and night. In fact, a total o f 58% (15/26) of the original sample reported they had no recollection of date, time, day or night, with nine of these attributing this to a lack of windows and a clock. The unit does, however, have a clock, though three subjects commented on its inappropriate size and position.

The study supported Keep et al's (1980) findings that the presence of windows is a means of reducing diurnal rhythm disturbance; all the patients who could tell the difference between day and night time had been nursed in the side ward where there are windows.

Transfer from ITU to a ward

In accordance with Jones et al's (1979) study, 13 subjects (52%) expressed that they had been pleased and not worried about their return to the ward, because they were on the road to recovery and nearer to getting home. Four sub- jects said they would not like to go back to ITU, recalling it as a shattering experience in which they had felt vulnerable. Two had not wanted to go back to the ward, purely because of their fear of pain on being moved and four subjects could not recall their transfer back to the ward.

Once back on the ward the subjects' per- ceptions often changed. Six subjects (24%, 6/25) commented on how difficult it was to adjust from a one-to-one relationship in I T U to the ward circumstances, and felt they had been spoilt in ITU.

Pre-admission visits

Only 4 out of the 5 patients in the sample who were admitted electively received a pre-admis- sion visit. This very small convenience sample precludes any conclusions, but findings of this part of the study are reported.

Only 2 of the 4 subjects interviewed prior to admission remember their pre-admission visit. Both were of the same age and gender, one having had repair o f an abdominal aortic

Patients' memory recall of their stay in an adult ITU 135

aneurysm and the other maxillo-facial surgery. Neither subject could remember the name of the nurse who had visited and only one could recall what had been said.

None of the subjects who had received a pre-admission visit recalled intense pain, with two having no recollection of pain and two recalling pain during physiotherapy. None of the subjects who had a pre-admission visit expressed any concerns about the equipment or alarms in ITU.

Only one subject from this group reported being unable to sleep and none experienced disorientation to date or time. All except one of the subjects, however, experienced dreams.

CONCLUSION

The objective of the study was clearly fulfilled by demonstrating that 92% of the sample were able to recall their stay in ITU, and their mem- ories are thought-provoking.

The findings are consistent with previous studies in respect of patients continuing to experience dreams, pain, sleep deprivation and worries about transfer out of ITU to a ward following the transfer.

One finding inconsistent with other studies was that in the current study more than half of the subjects (13/22) believed ITU to be a quiet place.

An area o f concern not directly addressed by previous studies was whether patients remem- bered the names of the nurses who cared for them in the ITU, and whether they recalled specific conversations or explicit explanations about the care they had received. The findings demonstrated that only 35% (9/26) of subjects could correctly recall their 'named nurse' in ITU, whereas 77% (20/26) could recall, in detail, explanations and reassurance they had been given by the nurse.

RECOMMENDATIONS A N D IMPLICATIONS FOR PRACTICE

The purpose of this study was not to generalise the findings to the speciality of ITU nursing, and indeed because of weaknesses in study design it is not legitimate to do so. The aim was to provide feedback about practice, and iden- tify problem areas which might be alleviated through a change in nursing practice within the IT U investigated. The limited findings from this small study can serve this purpose.

Feedback identified by the study included genuinely positive comments about all the ITU staff, in appreciation of their care and support not only for the patients but also for their friends and relatives. While such comments indicate feelings in subjects of research which are often implicated as a source of bias nonthe- less they are a boost to morale for the staff working in an ITU environment.

Other positive comments related to the patients' ability to hear. It is important to know that, even when heavily sedated, patients in this study were aware and perceived the ITU envi- ronment as 'quiet', and that therefore ITU nurses, who may feel uncomfortable talking to patients when a response is not received, must continue to talk to patients about their care, acknowledging their feelings and treating them as individuals.

Areas of concern highlighted by this study centre on an increased awareness of patients' feelings and fears. The first area of concern relates to patients' ability to hear staff discussion about care. All health care personnel may need reminding that any case conferences about indi- viduals should be carried out not only away from that individual, but away from other patients who may believe the discussion relates to them.

Another major concern to nurses is that patients may be in pain and this was reported by 69% (18/26) of subjects in this study. At times, it is extremely difficult for patients to communicate and for nurses to assess the nature of pain. The introduction of a precise pain assessment instrument for rating patient pain intensity is being investigated.

The number o f subjects who reported being unable to sleep in the ITU was double that found in other studies. This is a factor ITU nurses are aware of, hence the current protocol is to simulate day and night for patients. This is facilitated by the use of dimmer light switches or lamps at night, rather than the overhead bright fluorescent lights. Activity is also reduced at night, whenever possible. The fluo- rescent lights are, however, still perceived by patients to be extremely bright, therefore methods of alternative lighting such as 'filtered' lights should be explored.

Other factors affecting the ability to sleep related to uncomfortable beds, the oxygen masks and disorientation due to a lack o f win- dows and a clock positioned so that patients could read it. The first factor has been addressed with the successful purchase of new beds. Alternative suppliers of oxygen masks are being considered.

The lack of windows is again a factor known in the ITU. This design fault of some ITUs built during the 1970s is not something that can be addressed easily, and has often raised the idea

136 Intensive and Critical Care Nursing

of paint ing windows wi th a day and a night scene on a roller blind, either on the walls o f

the uni t or on the screens which form partitions be tween beds. This idea or an alternative needs to be given serious thought.

The inappropriate posi t ioning and size of the existing clock wi th in the I T U needs to be addressed, either by looking for alternative posi t ioning or a better designed clock that

enables patients to see it, no t only to tell the t ime but also whether it is day or night.

The effectiveness ofpre-admiss ion visits still

needs to be evaluated in a study with an appro- priate sample size. But findings from this study

have raised questions concern ing the method

by which the uni t staff conduct we-admiss ion visits. There is a need for this process to be for- malised with a structure that all nurses can fol- low, including provision of wri t ten evidence for the patient o f who their ' n a m e d nurse ' is going to be in ITU.

Other informat ion which should clearly be discussed at the pre-admission visit is the high

incidence of disturbing dreams experienced by

patients who undergo intensive care. It is

impor tant to ensure that patients talk about

these experiences, should t h e y happen, in order to clarify what has been a dream and what is reality. Knowledge about the equip- m e n t and tubes which may be used, along wi th pain assessment and alternative methods of communica t i on should be addressed at this

visit.

Ano the r area for improvemen t is the trans- fer o f patients back to the ward. This experi-

ence is still f r ightening for approximately 50%

of patients, especially if they con t inue to expe- rience psychological disturbances once in the

ward. The other difficulty some patients have

is adjusting to the ward circumstances after be ing extremely ill and becoming accustomed to constant at tention. This can really only be

resolved by the provis ion of a high depen- dency unit , where patients can more gradually get used to caring for themselves, bu t obvi- ously this has massive organisational and

resource implications. Closer links with the ward staff or rotation of

staffinto and out of I T U could promote a greater

understanding of the problems faced by patients and nurses before, during and after a stay in ITU.

The final r ecommenda t ion for change in nurs ing practice relates to I T U nurses visiting patients in the ward after their discharge from ITU. The study demonstrated that 69% (18/26) of subjects believed they wou ld have benfited from a visit by an I T U nurse fol lowing their discharge, to clarify aspects of their stay which were unclear and perhaps causing them concern. This visit would also be an ideal oppor tuni ty for I T U nurses to evaluate the pre-

admission visit, the patients' care during their stay in ITU, and provide cont inuous mon i to r -

ing of the themes addressed in this study. The visit wou ld need to be structured to allow for quantitative data to be collected.

The ideal person to perform such a visit wou ld seem to be the patient 's ' named nurse ' , wi th the ult imate aim of provid ing a final eval-

ua t ion o f the individualised care provided by that nurse for h is /her patient. The feedback

gained dur ing this visit wou ld have mean ing for the nurse and be more likely to produce

changes in practice to provide higher quality care.

The practice of visiting patients after dis-

charge from the I T U has implications for nurs- ing t ime and staffing levels, hence further stud-

ies are required to determine its feasibility.

ACKNOWLEDGEMENTS

The researcher is grateful to all the staffin the ITU for their invaluable support. The study was completed during the second year ofa BSc (Hons) Degree with the aid of a schol- arship from the Hospital Savings Association.

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