Phenomenological analysis of healthcare worker perceptions of intensive care unit diaries

Introduction: Studies have reported associations between diaries kept for intensive care unit (ICU) patients and long-term quality-of-life and psychological outcomes in patients and their relatives. Little was known about perceptions of healthcare workers reading and writing in the diaries. We investigated healthcare worker perceptions the better to understand their opinions and responses to reading and writing in the diaries. Methods: We used a phenomenologic approach to conduct a qualitative study of 36 semistructured interviews in a medical-surgical ICU in a 460-bed tertiary hospital. Results: Two domains of perception were assessed: reading and writing in the diaries. These two domains led to four main themes in the ICU workers’ perceptions: suffering of the families; using the diary as a source of information for families but also as generating difficulties in writing bad news; determining the optimal interpersonal distance with the patient and relatives; and using the diary as a tool for constructing a narrative of the patient’s ICU stay. Conclusions: The ICU workers thought that the diary was beneficial in communicating the suffering of families while providing comfort and helping to build the patient’s ICU narrative. They reported strong emotions related to the diaries and a perception of intruding into the patients’ and families’ privacy when reading the diaries. Fear of strong emotional investment may adversely affect the ability of ICU workers to perform their duties optimally. ICU workers are in favor of ICU diaries, but activation by the diaries of emotions among younger ICU workers may require specific support. Introduction Patient diaries were first used in Denmark, Sweden, and Norway, and then introduced several decades later in other European countries, such as the UK, Switzerland, and, finally, France [1]. Diary entries were found to fall into four main categories: sharing the story, sharing the presence, sharing feelings, and sharing through support [2]. The multiple roles of diaries kept for ICU patients include reconstruction of the illness narrative [3], communication of caring intent [4], debriefing to deal with posttraumatic stress syndrome (PTSD) [5], and the promotion of family healing [3]. ICU diaries have been reported to help in the transition of patients from critical illness to normalcy [2,5-8]. We previously evaluated the effect of an ICU diary on the well-being of patients and families and found that the diary decreased posttraumatic stress-related symptoms in both at 1 year after ICU discharge [1]. Our diaries, written in everyday language, included entries by ICU workers (including physicians) and relatives that were designed to help the patients to understand what happened to them during the ICU stay. Of 5,208 sentences in the 59 diaries used for the present study, 17.4% were written by ICU physicians, 22.7% by nurses and nursing assistants, and 59.8% by relatives [1]. Few data exist about the opinions of ICU workers regarding diaries. A qualitative study of ICU nurses in Sweden showed that the diary was perceived as giving the patient ownership of the ICU experience and recapitulating the ICU stay, although time constraints were cited as a reason to not open a diary [9]. The nurses thought that reading the diaries helped to guide patient * Correspondence: [email protected] † Contributed equally Medical ICU, Saint Joseph Hospital Network, 75014 Paris, France Full list of author information is available at the end of the article Perier et al. Critical Care 2013, 17:R13 http://ccforum.com/content/17/1/R13 © 2013 Perier et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. care but also reported negative effects, such as fear of reading what was in the diary [9]. Similarly, a study consisting of interviews of one nurse in each ICU in Denmark identified negative perceptions, such as feelings that experience was required to write in diaries for unconscious patients and that the diary constituted additional paperwork [10]. The objective of this study was to assess the perceptions of ICU workers contributing to the diaries. Materials and methods Setting and participants The ICU has 10 single-bed rooms and admits about 400 patients each year. Family members can visit around the clock, stay as long as they wish, and participate in patient care with the nurses. The ICU has a patient/nurse ratio of 2.5. The day team includes five full-time physicians and four residents. The criterion for including ICU workers in the study was experience with ICU diaries. To develop a comprehensive understanding of our study question, we used a sample of ICU healthcare workers who acquired experience with ICU diaries between May 2008 and November 2009, the earliest period of diary use in our ICU. In each category of participants (physicians, nurses, and nursing assistants), new participants were included until data saturation occurred. Collection and analysis of data In December 2009, we used semistructured in-depth interviews to assess ICU workers’ perceptions of the 59 diaries kept in our ICU. The characteristics of the patients for whom diaries were established are described elsewhere [1]. The interview was performed in the ICU in a quiet place by using an interview guide (Table 1) built by three physicians (MGO, CB, FP) and three ICU nurses (NC, SA, SB). All interviews were performed by the same physician (MGO), audio-recorded with the interviewees’ permission, transcribed verbatim, and evaluated by using interpretative phenomenologic analysis [11]. First, the transcripts were checked for accuracy against the audio recordings. Each transcript was read several times and then coded to identify initial themes, which were noted in the margins. This procedure closely resembled free textual analysis. Each reading had the potential to generate new insights. Then, themes recurring across transcripts were identified; recurring themes reflect a shared understanding of the phenomenon in question among participants. This stage involved a more analytic ordering of the data, as the researchers tried to make sense of the connections linking themes. Some of the themes tended to cluster. The process was dynamic and cyclic, with each transcript leading to the collection of further data and to their subsequent analysis. The aim was to recognize ways in which narratives from the participants were similar but also different. The researchers strove both to identify recurring patterns and to detect new issues, to take into account convergences and divergences in the data. The last stage consisted of producing a coherent ordered list of the themes. A clinical psychologist (AP) carried out the main analysis, and physicians (MGO, ARL) read the transcripts to improve the consistency and coherence of the analysis by ensuring that identified themes accurately reflected the data and that the analysis was not confined to a single perspective. The results were discussed during multiple meetings of the entire study team to determine when clarification was in order and whether the themes should be modified. To increase internal validity further, we distinguished clearly between statements by the interviewees and interpretations or accounts of those statements by the researchers [11,12]. In the Results section, we supply examples of interviewees’ statements to illustrate recurring themes. To protect confidentiality, identifying information was deleted from the statements. For this report, the statements were translated from French to English, taking care to preserve their meaning and feeling tone. Ethical committee approval The study was approved by the ethics committee (Comité de Protection des Personnes) of the Pitié-Salpêtrière Hospital, which waived the requirement for written informed consent. ICU workers participated on a voluntary basis and gave their permission for audio recording of their interviews. For each interview, the job title was indicated. Results The participant characteristics are displayed in Table 2. Interpretive phenomenologic analysis identified two domains of experience: writing in and reading the diaries. Four themes were identified: suffering of the families, giving information to families, determining the optimal interpersonal distance with patients and families, and reconstructing the patient’s story. Table 1 Interview guide Question 1 What reflections and feelings did you have when you read the diaries? Question 2 How did the diaries modify your relationship with the patients or families? Question 3 How did the diaries modify the information you delivered to the families? Question 4 How did you consider writing in the diaries to be a burden on your working schedule? Question 5 How did you consider the diaries useful for the patients or families? Perier et al. Critical Care 2013, 17:R13 http://ccforum.com/content/17/1/R13 Page 2 of 7