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An-Najah National University-Nablus
Faculty of Nursing
Experience of the patients who were being mechanically
ventilated in the Intensive Care Unit
A Descriptive phenomenological Study
Students
Mostafa Salamih Ahmad Dwaikat
Hamed Mahmoud Mohammed Aldireya
Khader jomaa
Instructor
Dr.Aidah Abu Elsoud Alkaissi
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Essay title:
Experience of the patients who were being mechanically ventilated in the
Intensive Care Unit. A Descriptive phenomenological Study.
Authors:
Mostafa Salamih, Ahmad Dwaikat, Hamed Hantouli, Mohammed Al-deryia,
Khader Joma’a
Topic:
Experience of the patients who were being mechanically ventilated
Level and Credits: BSc, 2Cr.
Course: Nursing Graduation Project
Supervisor: Dr. Aidah Abu Elsoud Alkaissi
Examiner:
Director of Nursing and Midwifery Department, Dr.Aidah Alkaissi at Faculty
of Medicine and Health Sciences
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Abstract
Introduction: Patients treated in an intensive care units are greeted by an
environment of technical equipment, where hoses and wires are connected to
different surveillance monitors. Patients who are unable to maintain adequate
oxygenation of the tissue supplied with an endotracheal tube which is connected
to a mechanical ventilator. To accept the endotracheal tube and treatment,
patients are given sedation and analgesics. In intensive care the nurse has a
central role in the treatment and nursing care- More research is needed to
improve patients experience in the intensive care unit and promote recovery.
The aim of this study was to describe the intensive care unit experiences of
patients undergoing mechanical ventilation.
Method: A descriptive phenomenological design, semi structured interviews
were conducted during 2013 with eight people, four male and four female, aged
from 16 to 60 years, (SD= ±16.2), (mean = 40.5 year), who were mechanically
ventilated in an intensive care unit for more than 48 hours in the northern and
central part of West Bank. Interview transcripts were analyzed using Giorgi
phenomenological analysis
Findings: Twelve themes and 26 sub-themes emerged: Being versus not being
informed, physical discomfort, psychological discomfort, safety in the ICU, feel
vulnerable and dependent, the technological environment around the patient, the
nurse's attitudes, struggling to be able to communicate, relatives significant,
memories and perception of time varied and regain control.
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Conclusion: Being dependent for survival on other people and technical medical
equipment created a sense of being vulnerable in an anxious situation and a
feeling of uncertainty about one’s own capacity to breathe. Having lines and
tubes in one’s body was stressful. As the people being mechanically ventilated
could not trust their body to function.
Key word: Intensive care unit; mechanical ventilation; phenomenology
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Acknowledgement
First of all, we would like to thank God for blessing us and
reconciling us in the life and in this project. And we want to express
our great appreciation to all who supported us in general and in
particular for all participants in the study, and we want to offer a
big thanks to our supervisor, Associate Professor Dr Aidah Abu
Elsoud Alkaissi Head of Nursing & Midwifery department who
spent great efforts to monitor us in this study, and for all the
personnel department who never hesitates to answer any questions
to help us, we want to express our great thanks to the institutional
review board at An - Najah National University, Palestinian
Ministry of Health, and we want to give our great thanks to
managers and staff of hospitals that allowed us to retrieve our data
from and collaborated with us in the recruitment of patients,
although we did not forget organizations that supported us
financially so we will give our great appreciation to the heads of
the (Al - Rajeh co. and al - Shams co.), and also for our families
who supported us along the way in conducting this study.
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TABLE OF CONTENTS
CHAPTER 1 ..........................................................................................1
SECTION 1
1.1.1 Introduction .............................................................................2
SECTION 2
1.2.1 Research problem ....................................................................3
1.2.2 Statement of the problem ..........................................................3
CHAPTER 2 ..........................................................................................6
SECTION 1
2.1.1 Research objectives ...................................................................7
2.1.2 Research question ....................................................................7
2.1.3 Background ...............................................................................8
SECTION 2
2.2.1 Literature review ....................................................................33
CHAPTER 3 - METHODOLOGY.....................................................11
3.1 Design ..............................................................................31
3.2 Georgi method ..................................................................31
3.3 Study participant ...............................................................23
3.4 Sample size .......................................................................23
3.5 Inclusion criteria ..............................................................23
3.6 Exclusion criteria .............................................................22
3.7 Setting / place ...................................................................22
3.8 Instrument / tool ................................................................22
3.9 Data collection .................................................................22
3.10 Data analysis ..................................................................22
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3.11 Pilot study ......................................................................28
3.12 Trustworthiness ...............................................................28
3.13 Credibility and dependability .........................................28
3.14 Ethical consideration ......................................................33
CHAPTER 4 .......................................................................................32
4.1 Finding .......................................................................................33
4.2 Discussion ..................................................................................66
4.2.1 Discussion of Methodology ...........................................67
4.2.2 Discussion of Finding ...................................................61
4.3 Conclusion .................................................................................83
4.4 Limitations ..................................................................................83
4.5 Recommendation ........................................................................82
4.6 Implications ................................................................................82
CHAPTER 5 .......................................................................................18
5.1 References ..................................................................................88
5.2 Annexs ........................................................................................12
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Chapter One
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1.1.1 Introduction:
Working in ICU means to work in a department where it is sometimes
necessary quick decisions and working with technical equipment,
Investigation and treatment where advanced devices and surveillance
monitors are used to monitor patient's medical condition. In intensive care,
patients who suffer from severe pathological conditions, accidents, trauma,
and other serious conditions such as patient vital functions are threatened or
fallers.
To be intubated and unable to communicate with its environment can
cause even more frustration for the patient. Therefore it is important that ICU
nurses have knowledge of and understand how best to facilitate
communication for the patient.
Therefore investigating self-experiences of those patients can be applied
in providing them with a better care by clinical personnel.
This study has chosen to do research on patients who are intubated and
is on respirator because this patient condition at the ICU and with high
technical devices promotes developing of certain experiences.
Aim of this study was to describe the intensive care unit experiences of
patients undergoing mechanical ventilation.
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1.2.1 Research problem:
Various studies worldwide have explored the experience of the patient
who was being mechanically ventilated in the intensive care units,
however there is no studies in Palestine that explore the experience of
these patients. Moreover, the information about the experience of being
mechanically ventilated is also limited.
In the various research, they found that patients have difficult
psychological experiences while they on mechanical ventilator, so in
Palestine we need to explore the intensive care unit experiences of
patients undergoing mechanical ventilation.
1.2.2 Statement of the problem:
Mechanically ventilated patients have a serious complains after
being weaned from the mechanical ventilation.
Mechanical ventilation refers to the movement of air through the
respiratory tract into and out of the lungs by means of a ventilator (Weller
& Wells, 1990:492). This implies that a ventilated patient is unable to
maintain spontaneous breathing efforts effectively and is dependent on a
machine to maintain this vital function.
Patients on the mechanical ventilator are subjected to extreme
physical and emotional stress in the intensive care unit, for example sleep
deprivation, sensory overload, noise as well as feelings of helplessness
and isolation.
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Dependency on a ventilator continually confronts patients with the
fragility of their physical condition and the possibility of permanent
disability or death.
Patients frequently question if they will ever breathe or function
independently again. The prospect of permanent disability threatens their
self-image and sense of worth. As they confront disability, they begin
the process of redefining their identity and mourning the losses that
physical impairment will bring (Belitz, 1983:43). Kotzé (1994:28)
supports this statement by stating that the seriously ill person is helpless
against his failing body. The condition for his existence now becomes a
threat to his existence. The patient’s body, which previously granted him
independence, now forces him to dependency.
Patients who are connected to a mechanical ventilator are unable to
communicate effectively with significant others owing to the
endotracheal tube placement that obstructs the larynx, thus preventing
voice production. This inability to communicate was thus the biggest
concern for patients who were connected to the ventilator. It has also
been previously documented that patients on a ventilator often
experience discomfort and frustration due to their inability to
communicate with others. This was intimately related to feelings of
anxiety, fear and agony, which created feelings of insecurity while they
were on the ventilator. In extreme cases patients can become
disorientated, delusional or psychotic (Bergbom-Engberg & Haljamae,
1993:41)
Patients who are dependent on a mechanical ventilator find
themselves immersed in an altered sensory environment. The altered
intensive care environment, procedures and routines, as well the feelings
produced by the inability to communicate, can cause psychotic type
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reactions such as paranoia, aggression and hallucinations, which are
termed intensive care unit psychosis or intensive care unit (ICU)
syndrome.
Sensory overload or deprivation and sleep deprivation are also
contributing factors for the development of this syndrome (Ashurst,
1997:49). Bucher and Melander (1999:554) state that excessive noise,
unfamiliar sights, offensive odors, continuous lighting and distorted
perception of time are some of the factors that can cause sensory
overload. According to Kidd and Wagner (1997:9) sensory deprivation
may result from factors such as restricted movements and lack of stimuli
such as touch and communication. Patients on mechanical ventilators are
constantly exposed to these factors and are thus prone to the development
of intensive care unit psychosis.
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Chapter Two
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2.1.1 Research objectives:
The purpose of this study is to explore the experiences of patients who
were being mechanically ventilated in the Intensive Care Unit in northern
and central west bank –Palestine, although in addition to the patient
experience to articulate some suggestion and recommendation to the
nursing team toward understanding of the patient expectations, and to
help health care team in promoting health.
2.1.2 Research questions:
What are the lived experiences of patients who were connected to a
mechanical ventilator?
What recommendations in the form of accompaniment guidelines can be
made to assist the registered nurses to enhance understanding and care of
patients on a mechanical ventilator?
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2.1.3 Background
Both life and death are interconnected with breathing. Breathing may
be considered both subjectively and objectively. The breath goes hand
in hand with human Emotions, energy, endurance and well-being.
Breathing is a way for man to react to different situations, when we
become frightened; we take a deep breath, severe respiratory seen Also
at the aggressor.
1. Intensive Care Unit
An intensive care unit (ICU) is perceived by many people as special,
strange and scary. Patients who come to the ICU with a life threatening
condition is met by an environment filled with high-technical equipment
needed to continuously monitor patient condition. ICU room is perceived
by many patients as frightening and inhospitable, the important patient
privacy is difficult to sustain (Bennun, 2003).
To care for an ICU also means that the difference between night and
day becomes blurred. Many times the light level is high, the lights are on
at all hours and appliances alerting and disrupt the normal circadian
rhythm (McKinley, Nagy, Stein-Parbury, Bramwell & Hudson, 2002).
Patients feel stressed by lights which disturb, sound becomes
indistinguishable and how the room is perceived different from a bedside
perspective. The technical equipment and treatment in the ICU such as
ventilator, the endotracheal tube or suction experienced as stressful and
strain of patients. Respirator experienced by some patients as a safety
and life support machine and other patients experience fear and
confusion (Fredriksen Call & Berg, 2007).
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2. Mechanical ventilation
A mechanical ventilator is a machine that generates a controlled flow
of gas into a patient’s airways. Oxygen and air are received from
cylinders or wall outlets, the gas is pressure reduced and blended
according to the prescribed inspired oxygen tension (FiO2), accumulated
in a receptacle within the machine, and delivered to the patient using one
of many available modes of ventilation.
Ventilator treatment: When the patient is no longer able to oxygenate
his blood or exhale CO2 (Price, 2001; Dybvik, 1997). It could be due to
chronic or acute respiratory failure. General conditions are acute
pneumonia, sepsis, acute Repertory Distress Syndrome (ARDS),
pulmonary congestion, atelectasis, and brain damage.
The concept of mechanical ventilation can be described as a respirator
provides the patient with air and oxygen with a gauge. Respirator main
mission is to support or completely take over the patient's work of
breathing (Rubertsson, 2005). The use of a respirator cannot be seen as
a way to cure a disease. Respirator gives the patient time to recovery
(Dybvik, 1997).
3. Sedation
In the 1970 - and 1980's strategy for sedation of critically ill patients
received continuous infusion of sedative and analgesic drugs. Patients
were heavily sedated both day and night. More recently, it has gone to
normalize patient's circadian rhythm, more alertness and thereby prevent
complications (Mazzeo, 1995; Wojnick-Johansson, 2001).
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Delirium is described as an acute reversible state of mind of a lack of
perception and cognitive function, increased or decreased psychosomatic
activity and disturbed sleep and wakefulness rhythm (Roberts, 2001).
Adequate sedation increases patient acceptance of respiratory therapy.
Specific Reasons to sedate the patient lying on a respirator include an
increased tolerance of the endotracheal tube, reduce anxiety, sound sleep
and synchronization with respirator (Mazzeo, 1995; Wojnick-Johansson,
2001).
Memories and experiences of intensive care
Delusions, nightmares, hallucinations and paranoid are memories that
patients describe after time in the ICU.
Patients usually remember more than dream as negative or scary,
characteristic of these dreams are real or threatening injury / death to
themselves or others. Patients with delirium are often frightening dreams
while non-delirium patients describe their dreams as pleasant but absurd.
Patients describe the dreams to stand in a queue to a burial, being buried
alive, how nurses are stealing their medications and they are captured
(Roberts, Richard, Rajbhandari & Reynolds, 2006).
4. Subjective Body
Man lives his life and reaching the rest of the world through his body,
which man existence is the central and the subjective body is both,
physical and psychological, existential and spiritual at the same time.
The body is enriched with experiences, lessons learned, memories and
wisdom throughout life, the body carries the individual's life history,
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self-image and sense, which are not separated in the body and the self
without the subjective body considered as a whole (Dahlberg, Segesten,
Nystrom, Suserud & Fagerberg, 2003).
5. Caring Relationship
Relational explained that how something or someone relate to
someone or something else.
If these words, health and relationship integration, describes it in a
health context as a relationship between two people. A definition of the
concept of care relationship can thus express as:
"A care relationship between a person acting as patient and a person
acting as professional careers, within any form of health care
operations." (Birch, 2007 p.18).
Good care must be take some time so that the patient feels a
participatory and through participation retrieves patient strength and
power, to be confirmed and give a social community with others despite
physical weaknesses.
A care relationship is unlike a normal relationship, a relationship in
which the nurse is those who have power. Patients describe the
relationship to the nurse to get good care and have an interaction with
the nurse and that they could get the patient to feel human, and important.
The presence of the nurse, patients experienced as helpful.
6. Role Of Families
Relatives have a significant role for the patient. They are described by
the patient as a support, reason to fight on. The presence of relatives gives
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the patient sense of security and protection when the patient felt helpless,
insecure and exposed.
Patients describe the role of families as to be affirmed, to be
understood, gain strength and feel secure. Relatives could understand the
patient's expressions or read lips for example if they were in pain. Being
able to recognize a relative's voice, smell or physical contact gives
patients peace of mind.
7. Problem Formulation
Breathing is described as the most fundamental mechanism in man,
and when breathing falters does this affect the patient negatively. Lack
of control, sedation and difficulties of communication are reasons why
the patient feels great anxiety. The environment around the patient, the
technologically advanced equipment, many different categories of staff
working around the patient and anxious relatives are demanding.
Many patients have absurd dreams, nightmares and unreal experiences
during time in the ICU. From previous research, it appears that especially
patients is sedated, intubated and connected to a respirator and a long
hospital stay has a greater far more difficult memories and experiences
from the ICU.
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2.2.1 Literature review:
A study was conducted 2011 in Sweden aimed to describe the reported
ICU experiences of patients undergoing mechanical ventilation. The
qualitative research interviews were conducted. Interview is a data
collection method that allows the researcher to access people’s
experiences in order to gain a deeper understanding and more accurate
interpretation of specific phenomena (Kvale and Brinkmann, 2009). The
sample was 9 people who had been experienced mechanical ventilation
and having tracheal intubation at least 24 hour and remembers part of
staying in the ICU, Eight participants answered the letter by signing a
consent form and were subsequently contacted by telephone and given
further information. Two themes emerged, firstly being dependent for
survival on other people and technical medical equipment created a sense
of being vulnerable in an anxious situation and a feeling of uncertainty
about one’s own capacity to breathe. Secondly having lines and tubes in
one’s body was stressful. (Engstrom, Nystrom, Sundelin, & Rattray,
2013)
A study conducted in 2009 in china aimed to understand patients’
intensive care experience while receiving mechanical ventilation in
intensive care units, study design was ontological phenomenological
approach guided by the insights of Martin Heidegger was used to
investigate patients’ lived experience of mechanical ventilator. The
patient inclusion criteria were a critical illness survivor admitted to ICU
and received mechanical ventilator treatment for at least 48 hours the
sample comprised 11 patients. There were three women and eight men,
with a mean age of 60 years (range: 33–78 years) , Five themes emerged
from the data: (i) being in an unconventional environment; (ii) physical
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suffering; (iii) psychological suffering; (iv) self-encouragement and (v)
self- reflection.(Wang, Zhang, Li, & Wang, 2009)
A study was conducted in 2009 in Iran. The study aims to investigate
self-experiences of the patients who are on mechanical ventilator can be
applied in providing the patients with a better care by clinical personnel.
Study design is a qualitative phenomenological survey. Data were
collected during five months by deep interview and then were analyzed
by Collizi's seven–stage method. Inclusion criterion was to undergo the
procedure at least once as well as age over 12 years and the desire to
attend the interview. Three female and 5 male participants from total of
8 in this research. They aged 12-75 years. Most of the participants
(62.5%) underwent MV between one week to one month and the rest
were connected either for less than 24hrs, less than a week or more than
a month. Two of the participants had been connected for more than once
while the rest had undergone just once. The sampling method was
purposeful and included eight participants. The findings of this research
were 3 categories (i) Interpersonal experiences , (ii) Extra personal
experiences , (iii) Intrapersonal experiences, experiences at the time of
connection and weaning which most of them are stressful and imposed
to them from the outside environment.(Arabi & Tavakol, 2009)
A study was conducted 2005 in Sweden, aimed to enhance the
knowledge and the understanding of the experience for the patient who
have been mechanically ventilated for specially the body awareness and
body image, grounded theory research method was used and an emergent
design that develop during the study was applied, deep interview was
conducted with 7 patient who have been treated with mechanical
ventilation, maximum variation sample was chosen according to the
following both women and men, variation in age, variation in length of
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time treated with MV, variation in reasons for admission to the ICU and
variation in time after discharge from the ICU. The study result was
affected body functions and difficulty to control the body; Changed
appearance; Existential thoughts; Not at one with the body; Lack of trust
in the body/themselves; Not in contact with reality and A feeling of being
restrained. (Johansson & Fjellman-Wiklund, 2005)
A study was conducted 2009 in Sweden, aimed to investigate adult
patients’ perceptions of endotracheal tube (ETT)-related discomfort at 5
days and 2 months after discharge from the intensive care unit (ICU).
The study design was prospective cohort study conducted over 18
months, from September 2003 to February 2005, Sample and Criteria
was that all consecutively admitted patients aged >18 years, who had
been intubated and mechanically ventilated, and who stayed in 1 of the
2 ICUs for more than 24 hours. Results were being dependent for
survival on other people and technical medical equipment created a sense
of being vulnerable in an anxious situation & stress.(K. A. Samuelson,
2011)
A study was conducted 2002 in South Afarica, The purpose of this
study was to identify, explore and describe the experiences of patients
who were connected to a mechanical ventilator. A non-probability,
purposive sampling method was used. This sampling method was
selected because the researcher was required to involve patients who
were willing and able to communicate their experiences. This was done
by means of a conscious selection of patients who met the requirements
of the sampling criteria set out by the researcher. The sample of the study
comprised a total of five participants, two males and three females. The
sample criteria was adults (18 years and over); all the participants used
in the study were adults ranging in age from 22 to 54 years of age; have
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been connected to a mechanical ventilator for a minimum period of 18
hours; three of the participants in the study were connected to a
mechanical ventilator for a period of 20-24 hours, while the other two
participants were long-term patients who were on the ventilator for a
period of almost two months; Once data was collected, interviews were
transcribed verbatim. Data was then analyzed according to Tesch’s
method as described in Creswell (1994:152). An independent coder
verified the identified major themes, namely: experiences of patients
related to the process of ventilation, as well as their experiences of the
environment while connected to the ventilator. A literature control was
also done to compare similarities and differences found in data analysis.
Ethical principles were maintained throughout the study. The identified
experiences formed the basis for the formulation of guidelines to assist
the registered nurse in the accompaniment of patients during the
ventilation process. (Jordan, Portia J., 2002)
A study was conducted 2006 in Sweden aimed to investigate the
relationship between memory and intensive care sedation. Its design was
prospective cohort study over 18 months in two general intensive care
units (ICUs) in district university hospitals. The sample was 313
intubated mechanically ventilated adults admitted for more than 24 h,
250 of whom completed the study. All 596 admitted patients were
eligible for enrollment in the study who were aged 18 years or over, had
been intubated, received mechanical ventilation, and stayed in one of the
two ICUs for more than 24 h. Exclusion criteria were: head injury,
intoxication, suicide attempt, psychotic illness, mental retardation,
hearing or talking disability non-Swedish-speaking, transference to other
hospital, and mechanical ventilation at discharge.
Patients (n = 250) were interviewed in the ward 5 days after discharge
from the ICU using the ICU Memory Tool. Patient characteristics, doses
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of sedative and analgesic agents, and sedation scores as measured by the
Motor Activity Assessment Scale (MAAS) were collected from hospital
records after the interview. Results: Patients with no recall (18%) were
significantly older, had higher baseline severity of illness, and
experienced fewer periods of wakefulness (median proportion of MAAS
score 3; 0.37 vs. 0.70) than those who had memories of the ICU (82%).
(K. Samuelson, Lundberg, & Fridlund, 2006).
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Chapter Three
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Methodology:
3.1 Design
The design used was a qualitative phenomenological descriptive design. This
design used to study the experience of the people by describing the aspect of
this experience by focusing on what exists. This design does not focus on
interpretation for the experience, but it will be an indicator for the people’s
thoughts and feelings (Wilson & Buttery Worth, 2000).
Our chosen design is primarily based on a descriptive approach
where our primary goal was to provide some explanation of about the
risks lays beyond the experience of being on mechanical ventilator.
3.2 Giorgi – Phenomenological Psychology
The method used is descriptive phenomenological human science,
which was found by Giorgi (1985). The aim of phenomenological
psychology following Giorgi (1971) is to produce accurate descriptions
of human experience. For this reason, phenomenologist operating within
this tradition mainly utilizes descriptions provided by others (obtained
through interview) (Giorgi, 1985).
The purpose of Giorgi’s phenomenological research is to capture as
closely as possible the way in which the phenomenon is experienced
(Giorgi & Giorgi, 2003b; Robinson & Englander, 2007) In Giorgi’s
work, phenomenology is used to look for the psychological meanings
that constitute the phenomenon in the participants’ life world.
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The idea is to study how individuals live, that is, how they behave and
experience situations (Giorgi, 1985). Their descriptions are based on
their experiences within the context in which the experience is taking
place.
Central to this research is the lived context of the individual. The
meaning of the phenomenon such as the experience of being on
mechanical ventilator in its totality and its relationships with its
particulars and therefore essences can only be seen in every constituent
of the meaning. The role of the phenomenological analysis is to discern
the psychological essence of the phenomenon (Giorgi, 1985; 1989).
The process of research in phenomenology starts with the
description of a situation as experienced in daily life (Giorgi, 1985). In
trying to obtain these descriptions, a researcher sets aside any prior
thoughts or judgment about the phenomenon under study. In so doing,
the researcher brackets the phenomenon. The bracketing or the epoch is
primarily undertaken in order to reveal the personal reality of the
individual for whom the phenomenon under study appears (Ashworth,
1999). What need to be bracketed are those presuppositions that have to
do with claims made from objective science or other authoritative
sources (Giorgi, 1986; Ashworth, 1999). Phenomenology attempts to
offer insightful descriptions of the way the world is experienced
perfectively rather than the way it is conceptualized, categorized or
reflected on (Van Manen, 1990). In this context, attempt suicide is at the
center of the inquiry.
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3.3 Study Participants
Phenomenology captures the phenomenon as it appears in daily life
(Cosser, 2005). The participants sample is the patients of being
mechanically ventilated in the ICU.
Participants recruited from governmental hospitals in the west bank.
Include Nablus: Al-Watani and Raphedia Hospital, Jenin: Jenin
governmental Hospital, Tullkarem: Thabet Thabet hospital, Rammallah:
Ramallah Medical Hospital.
3.4 Sample Size
The sample for this study is a purposive sampling (Polit, 2006).
Purposive sampling refers to precisely what the name suggests in that the
sample is chosen with a purpose in mind (Ritchie et al, 2003). The
researcher chose participants because they have particular features that
will enable understanding of the phenomenon under study (Ritchie et al,
2003). According to the Giorgi method, three interviews are sufficient to
achieve the purpose of the study (Giorgi, 1985). Semi structured
interviews were conducted with the patients. The total number of
participants was 8.
3.5 Inclusion Criteria:
The inclusion criteria is being on mechanical ventilator either by
tracheostomy or by endotracheal tube for at least 24 hour and in both
gender male and female with age above 15 year and being able to provide
data .
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3.6 Exclusion Criteria:
Patients admitted in the ICU and are not on mechanical ventilation,
disoriented patients, Patients under 15 years, and Patients who do not
speak Arabic.
3.7 Setting
The setting of data collection was the ICU of the governmental
hospitals
3.8 Selection of the Study Instrument
The interview process followed a semi structured interview guide
with different themes and underlying issues designed from the research
purpose and question. The interview guide acted as a support for those
important issues (Annex III). It also served as a designator of the order
in which different themes were to be addressed. We used the interview
guide as a checklist to ensure that all the themes were brought up instead
of letting the interviewer guide the conversation. This contributed to the
relaxed and natural aspect of the interviews, as opposed to a form of
hearing.
3.9 Data Collection
Interview subjects included patients were mechanically ventilated in
the ICU. The informants we interviewed obtained a consent form, which
we retained, and an information form, which they had to keep. Collection
was done through recorded interviews with eight patients. Each
interview was between 30 -60 min, sometimes longer description, which
in this study is that the interview began with a question about which the
informant was allowed to speak freely. We used as few questions as
possible in order not to project the interviewer’s own assumptions.
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Follow-up questions were asked only to get a more detailed and deep
description (Robinson & Englander, 2007).
Sound quality was excellent on all recorded interviews which
allowed that the interviews were easily transcribed. The interviews were
transcribed verbatim and all identifying features were removed to ensure
anonymity. All interviews were first listened through, printed and then
similarities were recorded in a meaningful merger operation. Some
quotes were saved in their original form.
Trustworthiness of the data was ensured by appropriate sample
selection to ensure credibility, showing the logic flow of the data
collection and analysis, and by verifying the findings with the informants
to demonstrate fittingness, or transferability of the findings (De Laine,
1997; Holloway & Wheeler, 2002).
The semi-structured interviews with patients reflected the experience of
being mechanically ventilated in the ICU. The interview focused on
information about: everyday life while being mechanically ventilated,
experiences of being mechanically ventilated, feelings and thoughts
while being mechanically ventilated, body during mechanical
ventilation, Interventions that felt good or less good. Memories and
dreams from the time spent in the ICU, experiences of communication,
experiences of comfort or discomfort, experiences of the environment in
the ICU and experiences of ending mechanical ventilation, experience
from family support, how do the patient feel toward nurses team, how do
the feel when drink for the first time, how was their behavior while they
were weaning from the mechanical ventilator.
The initial question to the patient was: what do you feel right now?
24 | P a g e
3.10 Data Analysis
Phenomenological psychologists analyse the data utilising a
systematic and rigorous process. Data analysis consists of four
consecutive steps where each step is a prerequisite for the next (Robinson
& Englander, 2007; Giorgi, 1985b, 1997). Prior to the analysis each
interview is transcribed verbatim. All steps in the analysis must be
performed within the phenomenological reduction (Robinson &
Englander 2007; Giorgi, 1997). Phenomenological reduction is used in
descriptive phenomenological analysis and requires bracketing as a first
step (Kleiman, 2004). According to Giorgi, bracketing/epoch implies not
taking a stand for or against but allowing the phenomenon to emerge
(Groenewald, 2004).
Phenomenological reduction also requires withholding any existential
claims and presenting data as it presents itself rather than making one’s
own conclusions about what is presented (Kleiman, 2004).
For essay writing, we continuously address theory, method and purpose
of the essay and the question as coherent and not as separate parts. The
analysis of the material was already in progress from the time we started
the collection of material. The thought of how we will analyze the
collected material had been with us from the beginning of the choice of
qualitative method. Designing the interview guide is a breakdown of the
various themes in addition to background information.
Step 1: Getting the sense of the whole statement by reading the entire
description
The entire interview protocol was read several times in order to get
a sense of the whole experience. The idea was to obtain a description,
25 | P a g e
not to explain or construct (Giorgi, 1989). Wertz (1985) suggests that
readers should see raw data as well as processed data.
The first reading, done in the natural attitude (i.e. the everyday
attitude) told the researcher to more actively identify and critically
examine his/her own interests, creditors learned, theories, hypotheses
and existential assumptions about the phenomenon and then set them in
brackets (Giorgi, 2005).
If certain passages of the collected material are unclear, it is
important that the author does not pad them with their own interpretation,
but instead goes back to the interviewee and asks for clarification
descriptions. If the author is unable to collect further information about
them, he/she will be later forced to describe the uncertainties that exist
in the data. Ambiguities and contradictions in the data may not be
reduced or declared the basis of possible interpretations, but must always
be described as such (Robinson & Englander 2007; Giorgi, 1985, 1997).
Step 2: Discriminating meaning units within a psychological
perspective
After going through the first step, Giorgi (1986) suggests that the
whole description should be broken into several parts to determine the
meaning of the experience and these are expressed by the slashes in the
texts (Giorgi, 1985) or by numbering of lines (Wertz,1985). Parts that
were relevant to the phenomenon that is being studied were then
identified. The process of delineating parts is referred to as meaning
units, they express the participant’s own meaning of the experience, and
they only become meaningful when they relate to the structure of all units
(Ratner, 2001). A word, a sentence or several sentences may constitute a
meaning unit.
26 | P a g e
Each meaning unit is constituent and therefore focuses on the context
of the text (Giorgi, 1985). The meaning units are correlated with the
researcher’s perspective and therefore two researchers may not have
identical meaning units (Giorgi & Giorgi, 2003a). This process takes
place within what is called reduction. It is important in
phenomenological psychology to withhold the existential judgment
about the experience of the participant.
Step 3: Transforming the subject’s every day expressions into
psychological language
The researcher returns to all of the meaning units and interrogates them
for what they reveal about the phenomenon of interest. Once the
researcher grasps the relevance of the subject's own words for the
phenomenon, the researcher expresses this relevance in as direct a
manner as possible. This is called the transformation of the subject's lived
experience into direct psychological expression. This is the step that
makes it clear through the description of the intrinsic meaning in the
material. Furthermore, the researcher must make clear the implicit
meaning of meanings which the text points to, i.e. make explicit what is
implicitly given. For that, transformation must be kept at a descriptive
level. It is essential; however, that it does not go beyond what is directly
given in the data.
Step 4: Synthesising transformed meaning units into a consistent
statement of the structure of the phenomenon.
27 | P a g e
This step is to make the meaning units coherent and synthesized by
relating them to each other to have meaning statements. Specific
statements are written for individual participants and a process of
analysis is used whereby common themes across these statements are
elicited and then form a general structural description, which becomes
the outcome of the research. (Robinson & Englander 2007; Giorgi 1985,
1997).
Sentence structure consists of the elements identified in the
previous step and understood through their relationships and the way in
which they are related to each other. Sentence structure is achieved by
the researcher as in step three, making use of imaginary variations to
arrive at the final sentence structure that cannot vary. All data must be
considered and the researcher must also have been adhering to a purely
descriptive language. If there are contradictions or ambiguities in the
material, this shall be described but not explained or understood in terms
of interpretations, theories, hypotheses or other existential assumptions.
If the context and other contextual factors are relevant to the
phenomenon, this must also be described. There are three levels at which
the structure can be described. The first level is the individual structure
that is based on a description from an informant. The second level is the
general structure that can be achieved by having multiple descriptions
(usually three). At the third level we find the universal structure, which
is located on a philosophical level. To find the general structure is always
desirable when it can be generalized to other people experiencing the
same type of phenomenon.
Once the description of the psychological structure of each
individual had been identified, the researcher looks at statements that can
be taken as true in most cases.
28 | P a g e
3.11 Pilot study
The above method was tested in the pilot study. The pilot study
involved one informant. The first case we were able to recruit from al-
Watani hospital. We contacted the hospital through written request to
meet the case. And we contacted the head nurse of the ICU. Consent
form was obtained from the patient who was informed about the study
orally and submitted in writing information for research (Annex I). The
agreement was available at interview. The interview was taped and the
text was treated in accordance with the above analysis. This pilot
interview included in the study sample.
3.12 Trustworthiness
Trustworthiness of the study focuses on methods to ensure that the
researcher has performed the research process correctly (Sparkes, 1998).
Trustworthiness criteria include credibility, transferability, dependability
and conformability (Sparkes, 1998).
3.13 Credibility and dependability
Matters relating to the implementation of interviews and analysis
can say something about the survey's reliability. Before the interviews,
the authors write down what they expected to find in the survey and be
conscious of how their backgrounds might color the survey. The authors
could thus limit their expectations by bracketing their previous
knowledge (Robson, 2002).
The author may, by making himself aware of his own attitudes,
become better listeners who try to put himself aside and take the dialogue
partner seriously. All interviews were recorded on a tape and transcribed
verbatim. This made the survey more credible than if the authors had
29 | P a g e
only taken notes during the interview (Robson, 2002).
Credibility refers to the trustworthiness of the data collection,
analysis and conclusion (Sparkes 1998). To ensure credibility, the
researcher therefore relied on the supervisor as a critic (Cosser, 2005).
Credibility of the data may also be related to whether respondents tell the
researcher the truth (Malterud, 2003). In this study we are looking for
experiences of patients of being on mechanical ventilator in ICU an
experience is subjective and thus true for the one who tells it.
We followed analysis model of Giorgi (1985) as described and tried
to be true to the stories of the participants. We selected in this study the
phenomenological approached to the theme, which gave us more aspects
to the findings. Using a developed analytical model gave us the
opportunity to test the analysis that was done (Robson, 2002).
The authors could discuss interpretations and reflections with their
supervisor at the transcription and interpretation of material which
increased the reliability of the survey (Kvale, 1997). The authors have
also tried to ensure reliability by clearly defining a purpose and clear
questions. Reporting methodology, selection criteria and implementation
of interviews and analysis of the collected material is likely to increase
the reliability of the survey.
Having ensured credibility, which is more concerned about the
validity of the study, it is not necessary to demonstrate dependability
separately (Babbie & Mouton, 2001).Where there is credibility,
dependability is also ensured. Dependability deals with the reliability of
the findings. For findings to be dependable, they must be predictable and
stable (Lincoln & Guba, 1985).
30 | P a g e
Evaluating the quality of phenomenological research
When presenting phenomenological research, its value is established
by honoring concrete individual instances and demonstrating some
fidelity to the phenomenon (Wertz, 2005). Research reports may, for
example, contain raw data such as participants’ quotations providing an
opportunity for readers to judge the soundness of the researcher’s
analysis.
The quality of any phenomenological study can be judged in its
relative power to draw the reader into the researcher’s discoveries
allowing the reader to see the worlds of others in new and deeper ways.
Polkinghorne (1983) offers four qualities to help the reader evaluate the
power and trustworthiness of phenomenological accounts: vividness,
accuracy, richness and elegance. Is the research vivid in the sense that
it generates a sense of reality and draws the reader in? Are readers able
to recognize the phenomenon from their own experience or from
imagining the situation vicariously? In terms of richness, can readers
enter the account emotionally? Finally, has the phenomenon been
described in a graceful, clear, poignant way.
31 | P a g e
3.14 Ethical consideration:
The study was approved by the Institutional Review Board (IRB)
of An-Najah national University (Annex IV). Patients were informed
about the nature of the study and the study objectives, the risks or
disadvantages of the study or data collection process and they were
informed that the collected data will treated confidentially and they have
a right to withdraw from it in any time and without any problem and we
will accept that respectively (Annex II), all of the participant were
signing the consent form to allow the participation in our research.
(Annex I).
32 | P a g e
Chapter Four
33 | P a g e
4.1 Finding:
The participants had been treated in the ICU for major traumas,
deterioration in conjunction with pulmonary disease and/or
postoperative complications. The duration of mechanical ventilation
ranged from two days and nights to up to six days. The participants were
aged from 16 to 60 years, (SD= ±16.2), (mean = 40.5 year) and included
were 4 men and 4 women. The participants began their attempts to
reproduce their experiences of being mechanically ventilated by stating
that they did not remember anything but after a while there was a
memory of certain images associated with the mechanical ventilation.
Most of the participants had shared their room in the ICU with another
patient
The analysis resulted in 12 themes and 26 subthemes. The themes and
subthemes (Table 1) are presented in the text below and are illustrated
with referenced quotations from the interview text.
Table1. The twelve themes and 26 sub-themes have emerged from the
experience of patients of being mechanically ventilated in intensive care
unit.
Themes Sub-themes
1. Being versus not being informed
1. State of chaos because of uncertainty
1.2 Did not realize what was happening
1.3 Being informed providing an important
degree of security and comfort
2. Physical discomfort
2.2 Pain
2.3 Thirsty
2.4 Drowsiness
2.5 Difficulty to sleep
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3. Psychological discomfort
3.1 Bored
3.2 Afraid
3.3 Confused
3.4 annoyed
3.5 Discomfort
4. Safety in the ICU
4.1 Being in a good environment
4.2 delivered into the hands of a bit of
machines
5. Feel vulnerable and
dependent
5. Need help with basic things
6. Dreams and nightmares
6.1unpleasant and frightening dreams
6.2 Pleasant dreams
7. The technological
environment around the
patient
7.1 A sense of being vulnerable in an
anxious situation
7.2 Suctioning of the endotracheal tube was
awful
8. The nurse's attitudes
8.1 Feeling safe with the staff
8.2 To be confirmed by the nurse
9. Struggling to be able to
communicate
9.1 Not being able to make themselves
understood
9.2 wanting to convey themselves
10. Relatives significant
10. presence of relatives gave power and
great support
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11. memories and perception of
time varied
11.That memories and perception of time
varied
12. Regain control
12.1 Reborn and given a second chance to
live
12.2 This body is not mine
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Table 2 : Analysis of the informant interviews
Units of meaning subthemes themes
"This is the most difficult, poor condition
of my life, shocked me when I woke up
and identified the new environment,
other patients in a coma, half naked
patient, the sound of the units, and no
one tell me where I am, I cannot speak
for to ask where is my family, I feel that
no opportunity to return back normal "
(B)
Another patient said: ‘‘I was never
really awake or able to orient myself to
where I was. I couldn’t turn myself in
bed to see where I was’’ (D)
"I want to talk to ask where my family
and my children, but I cannot, I need one
of my family to tell me what's going on "
(B)
"while I'm in intensive care department
for the first time I woke up and I could
not see anything and did not know
what's going on, I heard a voice
speaking to me said (relax, you are ok,
do not be afraid, you're in good hands,
you are on the respirator machine to
help with breathing so do not try to
remove the tube that is in the mouth, it is
for your benefits"(D)
"No one tell me where I am, the nurse
tell me you are in Hepron hospital to
prevent me to think of run away from
hospital, but I am in Jenin & the nurse
didn't told me that for my benefits' but
that annoyed me" (H)
State of chaos
because of
uncertainty
did not realize
what was
happening
Being informed
providing an
important degree
of security and
comfort
Being versus not
being informed
37 | P a g e
"pain of tube is the most difficult & I
have pain all over my body"(A)
"I felt so bad, especially when I see
needles location, it’s painful"(B)
"I know that the tube was providing o2
for me but its painfully" (H)
"I felt the pain so intense at my feet and
I feel pain in the back, I told the doctor
about it and he described to me
painkillers, and despite medication, I
still feel pain in my back"(B)
" I felt a great pain in my body from
staying in bed too long and also I have
a sore throat, I felt that there is a knife
in the throat when I woke up " (G)
"I feel a lot of pain, the pain from my
head injury and my leg fractures,
moreover tube in my mouth, it really
upset me and cause damage around my
lips, sore head as something hit my
head often and it was not relieved by
medication "(D)
"I have severe pain in the throat, the
body, it is difficult for me in ICU, I
cannot be able to move or speak, this is
a source of fear and stress, but it is the
test from Allah" (A)
"Death is better than re-intubation" (A)
pain
Physical
discomfort
38 | P a g e
"I have pain and discomfort from
foley's catheter" (A)
"I feel the pain all over my body and I
need to move from the bed, but I
cannot, though I cannot change my
position, I do not feel comfortable with
the urethra and needles and my stay in
bed"(B)
"I was ready to give everything that
countered the nurse to give me water "
(D)
"after I awoke, I found myself so
thirsty, I insist on consuming water
while it was dangerous for me, the
nurses refused to give me water, and
they explain why, but I just keep on
insisting and became anger on that by
word (hysteria status I developed), then
they give me water and I was tired after
that, and also felt guilty, so I give them
my apologize for what I've done, but I
repeat it in every time I felt thirsty "
(G)
Thirsty
39 | P a g e
" The most thing that make me
uncomfortable is drowsiness (G)"
" Actually, most things that make me
uncomfortable, such as drowsiness, as
a result of the effect of drug and light
and sound of machines also,
additionally how the nurses asks his
question, the question as a group to me
by the time I could not answer them, I
do not analyze what they mean " (E)"
"I cannot sleep normally, because I
have trouble breathing (COPD), voices
of interfering devices, no sleep without
medication, it was bad experience for
me (B)"
"I have difficulty in sleeping due to the
presence of nurses voice & machine
voices that’s annoyed me" (H)
"My sleep has changed from what I
already had. I sleep many hours here at
the hospital so I sleep all night and
during daytime approximately 3_4
hourly during the day and 12 hours at
night (C)"
"I could not recognize morning from
the night as it took me several days to
sleep before I woke up, and when I
woke up sound and lights make me un-
comfortable and makes sleeping
difficult for me with the exception of the
night, in fact I like night it is more
Drowsiness
Difficulty to sleep
40 | P a g e
quiet, so I got to sleep through the
night about 7-9 hours (D)"
" My sleep patterns have changed and
it has made me upset I used to sleep at
dark but here there are a lot of lights
that annoyed me, and I cannot sleep
normally because of the measures that
nurses make each period.(E)"
"I cannot sleep as I was sleeping in my
home, everything is different here, the
lights, voices, the restrictions on the
bed, smell and nurses voice. I tried to
cope, but I still have trouble sleeping
because I woke often"( F)"
41 | P a g e
"I was feeling bored from the
environment and I want to leave this
place as quickly as possible to return to
my family (D)"
"I feel so bored, I want to return to
school, to be between my family and
friends, even the drugs that I received
was somewhat painful, and I could feel
the blood that they gave me (E)"
"I got scared because I went into the
hospital for checkup, but when I woke
up I found myself on a mechanical
ventilator, and was confused by what is
already happening " (F)
After this illness & after I found myself
in ICU I felt that my life will be finish
& I will not see my children again and
that make me afraid & sad on myself"
(H)
"I was very scared and sad too and I
cannot make out what's going on
around me, how I got here and Whom
drove me. I was shocked with my stay
in one place for the first time I see and
the device looks strange and very scary
" (C)
"I had experienced negative feelings of
fear, grief, emotional pain, panic and
feelings of torture, then I feelings of
loss of confidence and powerlessness
and vulnerability "(A)
Bored
Afraid
Psychological
discomfort
42 | P a g e
"I was so scared, and I felt that it's over
and I will never return to normal life
and discharge home" (E)
"I feel fear from the environment of the
ICU, the died patient , and alarming"
(B)
"I was not aware of, but I could hear
voices that makes me confused because
I can hear the nurses voices, but I
cannot understand what is happening
or express
myself," she also repeat the words "I
was sleepy," and she said "these
nursing sound made me scared and I
question myself (what these people
want from me?) "(E)
"I felt confused, I do not know where I
am, and I had a tube in my mouth that
prevents me from talking and even that
was so painful, I got really anger and
sad at the same time" (E)
"I was annoyed, and I felt such rage
because I was good I also inquired
myself why this happens to me, it really
could be a medical error" (E)
"I have difficulty in sleeping due to the
presence of nurses voice & machine
voices that’s annoyed me" (H).
"When I was able to open my eyes, I
saw nurses and doctors, and I felt
Confused
Annoyed
43 | P a g e
something of fear and stress, more
things that I felt annoyed by it at the
time of removal of the tube, I feel there
is no chance to get my breath without
machine and I will die "(B)
"I was so upset by being connected to a
lot of tools, as it restricts my movement
on the bed. I could not move freely and
also the needles left a painful places
that I cannot tolerate it" (G)
"I was in very bad condition, I felt that
I'm in a prison, I can't move, this is the
worst thing happened with me in my
life" (H).
"At the beginning of period l have not
heard, feel and remember anything,"
when I start to hear the nurses and
doctors and machine, I felt discomfort
associated with intubation" (A).
"I'm always moving from place to
another, especially in my work, but
here I am handcuffed and it makes me
angry." (B)
"I tried several times to remove the
tube because it discomforted me a lot"
(D)
Restrained
44 | P a g e
"I feel secure in the ICU, because good
care and good communication,
submitted by professional nurse, and
high quality equipment" (A)
"I felt that the health team was so close
to me that they never left me alone, and
they always give me their support" (E)
“When I woke up I had the tube down
my throat and I had to depend on the
[ventilator] and all the drips and tubes
for my life. It was terrifying, thinking,
What if something goes wrong with one
of these machines and nobody knows?‟
After all, machinery is not infallible, is
it? I tried so hard not to panic too
much, but my whole life seems to lie in
balance in the hands of a bit of
machinery”(B)
Being in a good
environment
Delivered into the
hands of a bit of
machines
Safety in the ICU
"I need help with basic needs like going
to the bathroom or drink, I feel very
thirsty and asked to drink the water and
the first time the nurse wet my mouth
with cotton I tried to catch it, but do
not like to eat "(A)
" now I need help with everything that
drink, bath, and walk from the bed, I
felt too upset when I cannot move from
the bed to the toilet and the presence of
Pampers, its hard on me" (B)
" unable to perform normal daily
activities made me sad and upset, I
used to be active and this sudden
Need help with
basic things
feel vulnerable
and dependent
45 | P a g e
change is vague cannot be easy for me
" (F)
"The thing seems to be difficult is to be
controlled by others, to have
limitations and restrictions, says she
also "for example, I cannot drink water
whenever I want." (G)
"the tube make me uncomfortable and I
can't able to move to meet my basic
needs" (H).
"I dreamed of dead people, mother and
father, and even dreamed that I sit with
them and talk to them and I felt that I
have been among the dead, and I was
afraid that I may not see my sons and
daughter" (B)
"I have dreamed of when I was on
mechanical ventilation, these caused
some discomfort me but I did not
remember these dreams" (D)
"I dreamed about school, exams and
assignments, I see myself returning to
my normal life, playing with my friends
and from my family, it was so beautiful
dreams" (E)
Unpleasant and
frightening
dreams.
Pleasant dreams
dreams and
nightmares
46 | P a g e
"I could not see patients around me
during that period, but I've heard their
voices, and their groans.” (D)
"I heard alarms and noise that disturbs
, hoses and wires that make it
inconvenient and lights that dazzle" (D)
“The most thing that makes me un-
comfortable & makes me anxious! is
the voice of monitor device especially
when cable is disconnected from me
and the device gives a scary voice like
in the movies (Toot Toot) that makes
me afraid of death and a feeling of
uncertainty about one’s own capacity
to breathe "(D)
"I feel suffocated by the straw. patient
experienced cravings as a scraping or
scratching, and they describe it as
painful and uncomfortable, damaged
throat, burning sensation, I felt
powerlessness and pain" (A)
"The nurse asks me rise my hand if I
need to remove secretions from my
mouth, it makes me choke and painful,
but I am getting better when secretions
away" (B)
A sense of being
vulnerable in an
anxious situation
Suctioning of the
endotracheal tube
was awful
The technological
environment
around the patient
47 | P a g e
I know that the secretion makes me
anxious and irritable, and difficulty in
breathing, so it seems the suction was
good but painful and the nurse asks me
rise my hand if I need to remove
secretions, suction assisted to improve
ventilation (B)
“The suctioning was awful. I had such
a sore dry throat. I tried to show the
nurses how far to put the tube down so
it wouldn't hurt so much. At one time I
tried to cough it up, it was so ghastly
and irritating, I just wanted it out. But I
also knew that I probably needed it,
and the nurses weren't doing this just to
be cruel or for something to do. So I
ended up I gave up. What did it matter
how I felt?” (D)
"It was so difficult and hard, this
process tends to remove mucus and
blood that remains after mechanical
ventilator, "but I felt so comforted after
they make it, they repeat it every hour"
(F)
"Suctioning is like the thing that
remove all existing air from the lungs
and make me suffocated, but I felt good
after secretion removed" (H) .
"I am pleased with the excellent care
provided in intensive care with
technical equipment, I know I'm in
ICU, and I know the reason" (A)
"I felt happy because the support of
nurses, especially when they provide
medicine for me, I wanted to thank
them, but I cannot speak as the
presence of a tube, I cannot open my
Feeling safe with
the staff
The nurse's
attitudes
48 | P a g e
eyes and I saw the white screen only"
(A)
"throughout the period here in the
hospital, I feel the medical staff was
always by my side it makes me feel ease
and comfort in addition to the
wonderful nursing staff was always
close to me when asking them always
that I will find them and meet my needs,
I really thank them " (B)
"I feel comfortable when the nurses
give me such a medicine that relieves
pain and make me un-suffer from pain
in the head and his leg fracture, so I
was happy when the nurse come to
me"(D)
"I feel so satisfied by nurses and
doctors care they gave me, they keep
me back to life, they work a lot of time
to improve my health, thank them,
really I do not expect that we have such
high quality of health care in our
society".(D)
"nurses are better than doctors they
keep on finding what I need and they
are so cooperative, and I feel so happy
actually from the nurses" (E)
"I know of nurses interest in me, they
give me the best they can do"(G)
To be confirmed
by the nurse
49 | P a g e
"Not being able to communicate with
others, I tried to speak, but could not
make my voice heard because the
endotracheal tube which caused pain
and made it hard to form words with
the lips" (A)
" When I woke up and I found myself
cannot express in words, it was so
painful to feel like a speechless man "
(E)
"The most thing that makes me un-
comfort is the tube that I wake up to
find it in the throat, it is so bad to not
be able to say such a word (E)
“And it's quite strange because I
couldn't speak to them or I couldn't get
anything . . . yeah, like I couldn't say
“Hello it's me over here”. I couldn't
say that. And I felt like I was paralyzed
in the bed” (D)
Not being able to
make themselves
understood
Wanting to convey
themselves
Struggling to be
able to
communicate
"which also helped me is to have my
family with next to me"(A)
"my husband and sons' held much with
me, so they could respond much to me,
if there was something that was good, "
how important my husband was with
me during the hospital stay" (A)
Presence of
relatives gave
power and great
Relatives
significant
50 | P a g e
"I heard voice of my husband and my
sons talk with nurses about my
condition, but I can't able to move or
speak because I am under medication
effect " (A)
"family's love and encouragement is
important, I do not feel lonely, I feel in
touch with relatives as a reason to fight
for survival, through physical contact or
word, I felt a peace and security" (A)
"I feel better condition during the visit of
my sons and family, and want them to
stay all the time around me, I feel
depressed because I feel that the disease
takes away my family from me" (B).
"I feel reassured happy when I woke up
and saw my family, a feeling I will never
forget, when I felt grateful to God who
gave me the grace of life again" (C)
"I miss my sons and my home,
neighbors, I am tired of the atmosphere
of the hospital, drugs and tests routine
... I feel really bored I like to go out and
go back to my house" (C)
"I felt confident when I listen to my
family voices especially my brother
when he came to visit me and touch me,
I felt at that moment that no harm will
attack me while he was standing behind
me" (D)
51 | P a g e
"I felt so comfortable, when sometimes
I could hear one of my family voice"
(E)
"When I was sedated and on
mechanical ventilator I can hear my
voice being watched, and that's drive
me to feel some confidence and peace,
optimist, feel hope" (E)
"the presence of my family and their
visits are also so supportive of me" (G)
"through the beginning of my waked up
I did not feel of any person visit me, but
after that I had the ability to hear &
feel any person come to visit me,
specially my little son I feel safe when
he come to visit & touch my hand " (H)
"I felt joy when the tube was removed,
and begin to take back control of my
body again," I have experienced death
so present and feel that I have been
reborn and given a second chance to
live the soul is returned to me"(A)
"I could not stand up again and then I
saw the end coming"(B)
"Ooooh, the black days, I need a long
time to return back my power, I have
pain in all the muscles and bones, I
cannot move from the bed, I cannot
speak for I have serious sore throat"
(B)
"I was very happy because I was able
to communicate with the team, visitors
Reborn and given
a second chance to
live
Regain control
52 | P a g e
and my family, to be able to express
myself, drink and the pain becomes less
(E)
"It's not easy to see your body change
after being normal, I found really so
difficult to look at my hands that look
like dark spots and dry also the site of
needles so painful and even pipe
leaving the airway passage so ardent
and my voice already changed all these
things are hard and reduce my mental
status" (E)
"See how my hands look, they are not
beautiful and also my legs because I
feel so sad and upset, I'm so depressed"
(D)
This body is not
mine
1. Being versus not being informed
1.1 State of chaos because of uncertainty
Many of the patients experienced loss of control and reduced self-
confidence. They lacked the ability to orient themselves to time and place
and felt helpless. They were not always sure what was going on.
One patient said: " This is the most difficult issue of my life, it was as a
shock me when I woke up and identified the new environment, other
patients in a coma, half naked patient, the sound of the units, and no one
tell me where I am, I cannot speak for to ask where is my family, I feel
that no opportunity to return back normal " (B)
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Another patient said: ‘‘I was never really awake or able to orient myself
to where I was. I couldn’t turn myself in bed to see where I was" (D)
1.2 did not realize what was happening
Most patients reported the state of being shocked after they waked up,
they are not understanding what is already happening around them
One patient said: “I want to talk to ask where my family and my
children, but I cannot, I need one of my family to tell me what's going on
“(B)
1.3 Being informed providing an important degree of security and
comfort.
About half of participant reported that they were informed about their
condition after they woke up, and they mention the effect of this
orientation on their psychological status.
One patient said: "while I'm in intensive care unit for the first time I
woke up and I could not see anything and did not know what's going on,
I heard a voice speaking to me said (relax, you are ok, do not be afraid,
you're in good hands, you are on the respirator machine to help with
breathing so do not try to remove the tube that is in the mouth, it is for
your benefits" (D)
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2. Physical discomfort
2.1 Pain
Almost all patients reported their experience of pain during the period
of intubation even though the period that followed the intubation.
One patient said" I felt a great pain in my body from staying in bed too
long and also I have a sore throat, I felt that there is a knife in the throat
when I woke up " (G)
Other patient said "I felt the pain so intense at my feet and I feel pain in
the back, I told the doctor about it and he described to me painkillers,
and despite medication, I still feel pain in my back"(B)
2.2 Thirsty
Most of the patients expresses too much thirst after being disconnected
from the mechanical ventilator, when they woke up the patient describes
that as uncomfortable situation.
One patient said: "after I awoke, I found myself so thirsty, I insist on
consuming water while it was dangerous for me, the nurses refused to
give me water, and they explain why, but I just keep on insisting and
became anger on that by word (hysteria status I developed), then they
give me water and I was tired after that, and also felt guilty, so I give
them my apologize for what I've done, but I repeat it in every time I felt
thirsty " (G)
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2.3 Drowsiness
Drowsiness seems to be one of the most difficult things for most of
the participant, it’s the result of being sedated for some, and as a result
of physical trauma for other.
One patient said: "The most thing that make me uncomfortable is
drowsiness" (G)
Difficulty to sleep
Patients experienced a lack of orientation to time and place. They did
not know whether it was night or day, they complained distort
environment characterized by light, voices that prohibit them from
sleeping. Upon 'waking up' several patients reported that they felt totally
exhausted. In spite of this, it was often impossible for them to sleep, even
if they were no longer connected to the respirator or to the tracheal tube.
One patient said: "I cannot sleep as I was sleeping in my home,
everything is different here, the lights, voices, and the restrictions on the
bed, smell and nurse's voice. I tried to cope, but I still have trouble
sleeping because I woke often"(F)
3. Psychological discomfort
3.1 Bored
Feeling bored was described by several patients, who felt they were in
a strange environment, and wished to be with the family.
One patient said: " I was feeling bored from the environment and I
want to leave this place as quickly as possible to return to my family"
(D)
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3.2 Afraid
Most of patient were experienced feelings of fear, this was as a result
of the new environment which they found themselves in, they reported
that the sudden change in the environment with a little or no level of
information contribute to developing the fear, some describe their fear of
death and change also from not being able to back to normal
One patient said: "I was not aware of, but I could hear voices that makes
me confused because I can hear the nurses voices, but I cannot
understand what is happening or express myself," she also repeat the
words "I was sleepy," and she said "these nursing sound made me scared
and I question myself (what these people want from me?)" (E)
3.3 Confused
Almost about most of patients reported being confused, this confusion
comes with the same time the fear occurs, they usually result from the
changed in the environment, in addition to be not able to understand what
is going on this already contributed in the confusion .
One patient said: "I was not aware of, but I could hear voices that makes
me confused because I can hear the nurses voices, but I cannot
understand what is happening or express myself," she also repeat the
words "I was sleepy," and she said "these nursing sound made me scared
and I question myself (what these people want from me?)" (E)
57 | P a g e
3.4 Annoyed
The sudden change in the health status for some participant was very
annoying, furthermore the removal of the tube and the new strange
environment had a great role in this result.
One patient said: "I was annoyed, and I felt such rage because I was
good I also inquired myself why this happens to me, it really could be a
medical error" (E)
3.5 restrained
The sedative drugs which used to initiate the mechanical ventilation
process leave side effect which seems that discomforting the participants
moreover, the restriction of the ICU and the equipment which used.
One patient said: "At the beginning of period l have not heard, feel and
remember anything," when I start to hear the nurses and doctors and
machine, I felt discomfort associated with intubation" (A).
Another patient said: "I was so upset by being connected to a lot of tools,
as it restricts my movement on the bed. I could not move freely and also the
needles left a painful places that I cannot tolerate it" (G)
4. Safety in the ICU
4.1 Being in a good environment
They experienced the ICU as calmer than they had imagined and having
staff present made them feel safe
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One patient said: "I feel secure in the ICU, because good care and good
communication, submitted by professional nurse and high quality
equipment"(D)
4.2 Delivered into the hands of a bit of machines
During their time in the ICU the participants described a variety of
sensory inputs from the specific healthcare environment they found
themselves in. They said it was uncomfortable with all the tubes and
cables.
One patient said: “When I woke up I had the tube down my throat and
I had to depend on the ventilator and all the drips and tubes for my life.
It was terrifying, thinking, What if something goes wrong with one of
these machines and nobody knows?‟ After all, machinery is not
infallible, is it? I tried so hard not to panic too much, but my whole life
seems to lie in balance in the hands of a bit of machinery. (B)”
5. feel vulnerable and dependent
Participants described memories from the ICU of their body feeling
strange and vulnerable and being concerned about further deterioration.
They described how they had failed in several attempts to breathe by
themselves and felt that they needed the ventilator to be able to breathe.
They listened to the sound of the ventilator as they knew it was helping
them to breathe. They felt their bodies were weak and in a way paralyzed,
e.g. lacked strength to hold anything with their arms and hands and this
led to a feeling of being dependent on others and needing their help.
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5.1 Need help with basic things
The participants mentioned help with such things as personal care and
other activities they usually managed by themselves in their everyday
life. Their muscles had weaken and it took them a long time to get their
strength back. Not being able to go to the toilet was experienced as
especially demanding. Afterwards the participants appreciated being
alive and felt grateful to those people who had helped them.
One patient said: "I need help with basic needs like going to the
bathroom or drink, I feel very thirsty and asked to drink the water and
the first time the nurse wet my mouth with cotton I tried to catch it, but
do not like to eat" (A)
Another patient said: "unable to perform normal daily activities made
me sad and upset, I used to be active and this sudden change is vague
cannot be easy for me” (F)
6. Dreams and nightmares
Not remembering and having done things without being conscious of
them felt strange. It felt difficult not to know when and if things had
happened and participants also experienced dreams, nightmares and
problems with confused thoughts.
6.1 unpleasant and frightening dreams
One patient said: "I dreamed of dead people, mother and father, and
even dreamed that I sit with them and talk to them and I felt that I have
60 | P a g e
been among the dead, and I was afraid that I may not see my sons and
daughter " (B)
6.2 Pleasant dreams
One patient said: "I dreamed about school, exams and assignments, I
see myself returning to my normal life, playing with my friends and from
my family, it was so beautiful dreams" (E)
7. The technological environment around the patient
7.1 A sense of being vulnerable in an anxious situation
To be connected to high technical devices, continuous voices pattern,
lights provide sense of being weak and vulnerable, the patient reported
that this feeling was despite of all care which provided, and the fear of
death also was the consequence of this situation.
One patient said: "the most thing that makes me un-comfortable &
makes me anxious! is the voice of monitor device especially when cable
is disconnected from me and the device gives a scary voice like in the
movies (Toot Toot) that makes me afraid of death and a feeling of
uncertainty about one’s own capacity to breathe" (D)
7.2 Suctioning of the endotracheal tube was awful
The way participants were informed about suction and how to breathe
was important for their ability to feel safe.
One patient said: “The suctioning was awful. I had such a sore dry
throat. I tried to show the nurses how far to put the tube down so it
61 | P a g e
wouldn't hurt so much. At one time I tried to cough it up, it was so ghastly
and irritating, and I just wanted it out. But I also knew that I probably
needed it, and the nurses weren't doing this just to be cruel or for
something to do. So I ended up I gave up. What did it matter how I felt?”
(D)
8. The nurse's attitudes
8.1 Feeling safe with the staff
The participants said that it was essential that they trusted and had
confidence in the staff for them feel safe in the demanding situation as
they were in. By knowing what would happen the participants were able
to prepare for examinations and interventions. When the participant
woke up they felt uncomfortable to have the tube in their throat and they
also felt uncomfortable because they were thirsty. In some situations they
were not allowed to drink anything, just to wet their mouth, which felt
like torture and when staff then wet their mouths with swabs or sticks it
felt wonderful. They described being troubled by phlegm in the tracheal
tube and that it felt unpleasant when the staff had to suction it away. One
participant described an occasion when there was almost a blockage in
the tube and the anxiety ridden seconds before it could be removed by
the staff.
One patient said: "I feel so satisfied by nurses and doctors care they
gave me, they keep me back to life, they work a lot of time to improve my
health, thank them, really I do not expect that we have such high quality
of health care in our society ".(D)
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8.2 To be confirmed by the nurse
Most of patients reported the importance to be informed about the place,
time, and what is already happening, which described to be so important
in alleviation of the most of bad experiences, in addition it was seen so
important to be accepted by the nursing team the thing which provide
confidence and trust.
One patient said: "I know of nurse's interest in me, they give me the best
they can do"(G)
9. Struggling to be able to communicate
The participants described how hard it was not being able to
communicate verbally. They could not talk due to weakness and tubes in
their mouths and throats. They said that it would have been good to be
able to use sign language. Not being able to make themselves understood
led to feelings of panic and frustration. They tried to speak, mime and
write messages, without success. It was difficult just to shape the mouth
to try to express oneself and mime the words.
9.1 Not being able to make themselves understood
To be unable in expressing the self was so difficult for about most of
patients, they explain that being not able to communicate with others
gave them a sense a pain and annoyed.
One patient said: "Not being able to communicate with others, I tried
to speak, but could not make my voice heard because the endotracheal
63 | P a g e
tube which caused pain and made it hard to form words with the lips"
(A)
9.2 wanting to convey themselves
To feel of being an object and unable to get the attention of others was
reported by some patient to be so difficult issue.
One patient said: “And it's quite strange because I couldn't speak to
them or I couldn't get anything . . . yeah, like I couldn't say “Hello it's
me over here”. I couldn't say that. And I felt like I was paralyzed in the
bed” (D)
10. Relatives significant
To some patients it is important that the family is present. This is their
lifeline and their bright spot in a dismal situation. Although the patient’s
own family is important, and consolation that the staff could not provide.
Close relatives led the participants to think about other things than their
illness and they mostly understood what they tried to say, which was very
valuable.
10.1 Presence of relatives gave power and great support
The participants appreciated having their close relatives present
during their stay in the ICU as they gave support. To some patients it is
important that the family is present. This is their lifeline and their bright
spot in a dismal situation. Although the patient’s own family is
important,
One patient said: "family's love and encouragement is important, I do
not feel lonely, I feel in touch with relatives as a reason to fight for
64 | P a g e
survival, through physical contact or word, I felt a peace and security"
(A)
Another patient said: "I felt confident when I listen to my family voices
especially my brother when he came to visit me and touch me, I felt at
that moment that no harm will attack me while he was standing behind
me"(D)
11. Memories and perception of time varied
The participants’ memories from the time they were mechanically
ventilated varied in degree and extent.
Although they appeared to be sedated and beyond consciousness they
emphasized that they had memories from this period. But the opposite
was also described where participants had been told they had been awake
and had said and done various things, but they had no memory of them.
Not remembering and having done things without being conscious of
them felt strange. It felt difficult not to know when and if things had
happened
One patient said: "I do not remember the time I was on the mechanical
ventilation device that is exactly where like a dream, but a deep, I could
hear one time voices around me"
The patients experienced lack of orientation to time and place. They
did not know if it was night or day, or how long they had been in the
ICU. They did not know if they were connected to mechanically
ventilated device.
One patient said: "When I slept I do not know or feel anything, I do not
know where I am and if it is day or night. When I woke up and they said
65 | P a g e
I was connected to mechanically ventilated device, I was scared "If I had
known that I was on a mechanical ventilator, I absolutely would die"
Another patient said: "I remember hearing some nursing voices, but
they were not clear sometimes I could hear my family voice, but I had no
memory of them"
12. Regain control
12.1 Reborn and given a second chance to live
To find the self-awake after being unconscious, regain this
consciousness was described as to be reborn or regain the life and having
second chance to live.
One patient said: "I felt joy when the tube was removed, and begin to
take back control of my body again," I have experienced death so present
and feel that I have been reborn and given a second chance to live, the
soul is returned to me"(A)
12.2 This body is not mine
Waking up was experienced as emptiness of the mind and body, the
uncertainty of not knowing what was happened and whether it was night
or day, changed body appearance, hands looks different from the needles
and their sites also turn to purple.
One patient said: "It's not easy to see your body change after being
normal, I found really so difficult to look at my hands that look like dark
spots and dry also the site of needles so painful and even pipe leaving
the airway passage so ardent and my voice already changed all these
things are hard and reduce my mental status " (E)
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Discussion Method and finding
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4.2 Discussion
4.2.1 Discussion of the study method
This study tried to focus on the experience of the patient who were
being mechanically ventilated in the intensive care unit. By the time it seems
so important to understand these experiences because we have little
information about them.
In this study, to develop a clearer understanding the patient who were
being ventilated experiences, we used a qualitative descriptive
phenomenological approach to glean the specific life experiences of these
patients. Hallett (1995) claims that the phenomenological approach, which
focuses on the subjective experience of the participants, is a natural and
rational method for understanding human experience. Descriptive
phenomenology is a useful approach because it analyses personal
experience, thereby allowing researchers to explore the actual experiences
of carers (Mu 2000; Huang et al. 2006). Phenomenological enquiry is the
description of phenomena as experienced by an individual. It focuses on the
participant’s subjective perceptions and gives the researcher an
opportunity to study phenomena in depth (Morse & Field 1996).
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Our study used the phenomenological descriptive design to understand the
experience that the intubated patients face during the period of being on
mechanical ventilation device and in the ICU. This design allows exploring the
participants lived experiences and formulating them into psychological
understood language that is the essence of phenomenological design
(Englander, 2007).
To obtain the goal of the study, face to face deep interviews with
participants were conducted and the interviews were tape recorded to ensure not
to miss any information. All interviews were transcribed verbatim in order to
be prepared for analysis.
The analysis was based on Giorgi phenomenological psychological
analysis that transforms the lived experience of ideas to words that can be easily
understood (Giorgi, 1985). The role of the phenomenological analysis in this
respect is to discern the psychological essence of the phenomenon (Giorgi, 1985,
1989).
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4.2.2 Discussion of the finding:
The study provides a rich description of lived experience and adds to the
knowledge and understanding of the patient perspective of critical illness and
being mechanically ventilated, giving way to new insights, the aim of this study
was to describe the intensive care unit experiences of people undergoing
mechanical ventilation. People who had been mechanically ventilated described
how they had suffered from sudden and unexpected events where the perception
was that life itself was threatened. The body and its functions, previously taken
for granted, were changed and they needed other people in order to be able to
manage what they could do for themselves before.
According to the findings of our research, the patients who were undergone
mechanical ventilation have different experiences during the period of being treated
by mechanical ventilator which imposed to them from the outside environment. The
themes that emerged from our study interviews were 12 major themes and 26
sub- themes:
1. Being versus not being informed
One of the themes emerging from this study is being versus not being informed.
We found that some participant were received information about where they are,
information about what is already happening with them, while in the other hand
some other patient weren’t received any of these information, which resulted to drive
them anxious and confused.
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Our study found the importance to be informed as an intubated patient in the
intensive care unit, and mention the effect of this approach, also our research
confirmed by previous studies. Being informed helped patients to feel safe, to have
confidence in nurses and reduced their anxiety. Although McKinley, et al. Study
(2002) showed that patients appreciated the information including on its condition
and whether the progress they made. When they got this information, they felt that
recovery was "faster”. Being intubated meant that information was experienced
particularly significant. In the same study by McKinley et al. (2002) described
patients' primary experiences of not getting information in terms of vulnerability,
fear, and confusion / disorientation. Some intubated patients have problems with
nightmares, hallucinations and delusions during hospitalization in the ICU. For
patients still perceive control over their existence requires ICU nurses provide
repeated information and constantly offer the patient reorientation (Johnsson, 2004;
Carroll 2004).
When intubated patients realized that they could not communicate and did
not receive information about their condition, they felt shock and fear. Some
patients felt that they were deliberately ignored and that the nurses withheld
important information (Jablonski, 1994). Some patients reported that they did
not understand why they could not speak and the endotracheal tube was
temporary. Relevant information had reduced their anxiety about not being able
to speak. One patient stated: “A surprise ... no one had told me that I was unable
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to speak. Should I really have under stood that myself? “(Wojnicki Johanssen,
2001, p.36). In order to know what information the patient wishes, it needs at the
nurse must know the patient. It is therefore important to have a close relationship
with the patient to provide individualized information (Hafsteinsdottir, 1996).
2. Physical discomfort
Other theme which emerged from our study was the physical discomfort. Our
study shown that’s to be intubated in the intensive care unit as a patient this imposed
a lot of factors such as to be thirst, pain from the tubes needles, staying in the bed
for long period also from the suctioning process, drowsiness either from being
sedated or as a result of physical injury, difficulty to sleep, all of these factors
contribute in the physical discomfort. This finding approved by the previous
research and studies which shown the similarities with us. Reasons why patients
could not speak. The endotracheal tube caused pain and made it difficult to form
words with the lips. It was also difficult to drive need of suction and that
secretions removed (Fowler, 1997). Some of the patients experienced difficulty
in breathing. They felt that they were not getting air and thought they would
suffocate. While patients struggling to breathe, they tried to communicate the
need for more air (Hafsteinsdóttir, 1996).
pain in relation to mechanical ventilation (Coyer et al.,2007), pain has been
a major issue in the present study in spite of the sedation strategy has evolved
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toward primarily relieving the pain, Despite the discomfort and fear, the patients
did not find mechanical ventilation intolerable.
Suctioning of the endotracheal tube is a situation that was perceived as the
worst single act during treatment with a respirator, it was perceived as annoying
and unbearable (Wang et al., 2009; Jablonski, 1994). Suction meant that patients
received bolus sedation and the patient experienced it as hovering between in
and out of consciousness (Magarey & McCutcheon, 2005). Patients experienced
suction as a scraping or scratching, and they describe it as painful and
uncomfortable.
Johnson and Sexton (1990:48) supported our result about the endotracheal
tube effect in their exploratory study conducted regarding the factors that were
distressing for the patient during mechanical ventilation. They suggested that a
major source of distress for patients on the mechanical ventilator was pain and
discomfort caused by the presence and necessary care of the endotracheal tube.
Hweidi (2007) shows that having tubes in the nose or mouth, being thirsty and
not being in control of yourself were considered as the main stressors by
participants.
As a nature the human body need to rest through enough and good sleeping,
but the study show that the many participants were unable to follow their normal
sleep pattern in the ICU, was as a result of the new environment, patients'
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statements show that sources of sensory overload such as noise, nursing care
activities, and treatments given to both themselves and other patients all
contribute to lack of sleep, our study confirmed with previous studies which
show about the same result.
In previous literature, the environmental factors are noted as having such
influence. But this study also revealed that to be tired out, and totally exhausted
seemed to make sleep and rest more difficult. Thoughts and uncertainties
together with feelings of tension also contributed to lack of sleep. Indirectly,
patients' fear of the equipment, the realization of their acute condition, and the
possibility of loss of existence, influenced their ability to sleep and rest. Even
the nurses telling the patients to sleep and rest sometimes created a fear of not
being able to wake up again. But there are also more concrete factors which can
influence the patients' ability to sleep, such as an uncomfortable bed and the fear
of violent patients in the same room. It is known that the quality of sleep is
affected postoperatively (Aurell & Elmqvist 1985; Edtll-Gustavsson et al 1997).
Rapid eye movement (REM) sleep also decreases or disappears completely
during treatment with opioids and benzodiazepines (Hartman 1977; Hayter
1980), which may also contribute to the feeling of being unable to sleep and
exhaustion.
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3. Relative significance
It was shown from our study the importance of the family and friends support
on the patient psychological status and ability to cope with the new environment,
and also in successful recovery process, about all participants reported this as a
major factor in enhancing their condition.
This result was approved by several previous research, which shown that the
importance of the relative support. People who had been mechanically ventilated
described how important was the support of their close relatives (Engstrom and
Soderberg, 2007). Close relatives can give the patients the strength and
motivation to keep fighting.
Through support from the relatives, patients could better manage the negative
experiences of the deteriorating communication. Patients experienced related to
a communication link between them and the nurses. Closely could also interpret
patients' gestures and needs to nurse. (Hafsteinsdottir, 1996, p 266).
Patients were fully agreed that family presence was crucial to their recovery
(Wang et al., 2009; Granberg et al., 1998; Jablonski, 1994; Granberg et al.,
1999). Family members perceived as the real world, it was relatives who took
the patient back to reality again. Patients felt calmer when relatives were with
them, a sense of security. Patients could recognize a relative's voice and the way
they were moving in the room or how they touched the patient (Granberg et al.
1998). Knowing the family's love and encouragement, to not feel alone and
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weak are descriptions of relative’s importance.
Eisendrath (1982) points out that it is particularly helpful if a close family
member is able to spend the day with each patient helping to inform and
orientate them and as MacKellaig (1987) stated, to help to give them their sense
of identity in order to avoid feelings of loneliness and isolation. Jablonski (1994)
has also emphasized that relatives help the patients to cope with their illnesses
and the restrictions placed upon them by attachment to the ventilator. Relatives
also seemed partly to protect the patients against the horrible experiences of fear,
time confusion and anxiety. It is possible that the presence of important familiar
others assisted the patients to concentrate and to focus their attention and will.
Morse (1997) mentioned this as 'anchoring to significant others', which helps
the patient to maintain a sense of self, identity and reality. The question is
whether the presence of relatives means that the development of an ICU
syndrome or increasing fear can be stopped or limited because the relatives help
the patients to bring order into the chaos. The experiences of being completely
empty of emotions when 'waking up' after sedation could be seen as because the
patients are still in a state of chaos.
Some patients in the study describe the ICU as unfamiliar and different from
their usual way of being in the world. In spite of communication difficulties,
patients sought to reclaim their known world by connecting or re-engaging with
their families in the ICU. The presence of family is important for some the
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family is their lifeline and helps them to recover and move out of the ICU.
Bergbom and Askwall (2000) found that suffering from severe disease or injury
results in not only a threat against the person as an individual, but also against
the individual as a part in the world. The threat can, however, be neutralized by
the presence of their relatives (Takman and Severinsson, 2006), because this
represents fellowship, togetherness and participation that can help to maintain
the patient’s identity and individuality (Hewitt, 2002). Johnson (2004)
concluded that the presence of caring relatives provided an enormous source of
comfort to patients.
4. The technological environment around the patient
One of the important theme which emerged from our study is the
technological environment around the patient, patient reported their feeling of
being vulnerable and weak as a result of being connected with high
technological devices, this vulnerability perceived as being dependent on a
machines to live, the way participants were informed about suction and how to
breathe was important for their ability to feel safe.
This result was confirmed by several previous studies (Fisher and Moxham
(1984, MacKellaig 1987). The patients' awareness and perception of different
equipment connected to their bodies resulted in questions and thoughts such as
'Am I that ill?' The lines may be experienced as discomforting - 'tubes and
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lines all over me, The technical equipment used in intensive care seems to be
responsible for the development of thoughts such as existential questions and
ponderings. These feelings of being captured may also result in unpleasant and
uncomfortable bodily positions. The equipment closest to the patient is viewed
from a limited perspective, making it difficult to see the surroundings and
other activities. It is difficult for patients to understand the type of equipment
being used, and which they are connected to.
The equipment is included in the ICU stressors identified previously (Fisher
& Moxham1984). The equipment results in limited and decreased mobility, and
discomfort for the patient. Fisher and Moxham (1984) and MacKellaig (1987)
have stated that for pat lying on their backs, tied to machines (even if this is a
means for survival) often causes feelings of fear and helplessness and difficulties
in often tarring to their position in the room. This can result in body image
distortion and altered self-conception (Kleck 1984; Clifford 1986; Platzer 1987).
Morse (1997) suggests that in stage 3 of the process she describes, the patients
endure to live and regain their self In this stage, patients learn to 'bear it' and
tolerate or stand pain and uncomfortable treatment and activities. In this study,
when patients described their experiences of equipment, this phenomenon can
be discerned. But it also shows that the equipment can create an increase of fear
and tension, threatening the patients' fragile existence.
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5. Struggling to be able to communicate
One of the most important theme that the state of being struggling in order
to communicate either with the family or with the nurses, the participants
illustrate how difficult it was unable to communicate verbally. They couldn’t
talk due to weakness and tubes in their mouths and throats. Not being able to
make themselves understood led to feelings of panic and frustration.
This result was shown to be approved by the previous research and studies which
said that:
Impaired communication with nurses and family was described as
embarrassing. Communication during mechanical ventilation has been
discussed in other studies, where poor communication not only caused anxiety,
but also contributed to a slower recovery (Patak et al., 2004). The findings
indicate that patients find good communication in ICU both therapeutic and
reassuring, while poor communication is experienced as distressing (Russell,
1999; Magnus and Turkington, 2006). Although the patients in our study were
troubled by inability to communicate properly, they found that nurses were
excellent communicators in these circumstances.
The nurses made an effort to understand the patients by asking and by using
gestures, sign language, paper and pencil, Most importantly, the nurses were
able to anticipate many of the needs of the patients who had been mechanically
ventilated experienced difficulties communicating and stated that they were
unable to use their voice to talk, which was frustrating. The problem of ICU-
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Acquired Weakness is now well documented. Patients can lose significant
muscle mass during an episode of critical illness (Griffiths and Hall, 2010), and
whilst this is commonly associated with a prolonged recovery period, it can
impact upon these simple activities such as writing. The ability to communicate
either in writing or verbally is important for conveying one’s thoughts to others.
Wang et al. (2008) describe people’s experiences of communication difficulties
associated with mechanical ventilation, where losing the ability to communicate
creates feelings of dependency, vulnerability and powerlessness. Karlsson et al.
(2012) show that being voiceless was considered the worst experience by
participants who were mechanically ventilated and that the discomfort and pain
caused by the tracheal tube was considerable. Hweidi (2007) shows that having
tubes in the nose or mouth, being thirsty and not being in control of yourself
were considered as the main stressors by participants.
6. Safety in the ICU
We found that some patients felt in safe in the ICU, as they were present in
a good hands and in high quality care, also some others not felt in safe and
describe it as stressing environment. This also confirmed with other studies
which shown the similarities of our result: People who had been mechanically
ventilated said that they felt safe with the staff and it has been reported that
approximately 70% of patients indicate that they felt safe whilst in ICU (Rattray
et al., 2004).
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The participants said that it was essential that they trusted and had confidence
in the staff for them, feel safe in the demanding situation as they were in. By
knowing what would happen, the participants were able to prepare for
examinations and interventions. They said they were not able to be involved in
decisions about whether or not to start mechanical ventilation treatment; their
relatives or the staff had made that decision. When they woke up it felt
uncomfortable to have the tube in their throat and they also felt uncomfortable
because they were thirsty. In some situations they were not allowed to drink
anything, just to wet their mouth, which felt like torture and when staff then wet
their mouths with swabs or sticks it felt wonderful.
They described being troubled by phlegm in the tracheal tube and that it felt
unpleasant when the staff had to suction it away. One participant described an
occasion when there was almost a blockage in the tube and the anxiety ridden
seconds before it could be removed by the staff. The way participants were
informed about suction and how to breathe was important for their ability to feel
safe. (Engström, Nyström, Sundelin, & Rattray, 2013).
While some other participant describe the environment of the ICU by saying
such sentences describe the difficulty of tolerating the place:
“After this illness & after I found myself in ICU I felt that my life will be finish
& I will not see my children again and that make me afraid & sad on myself"
(H)
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And this confirmed with other studies that shown the similarity of this result:
The environment in the ICU is described as inhospitable, an environment that
patients experienced as being in a different world. Alarm, the patient in the next
bed and the staff was experienced all that distracting (Wang et al., 2009). The
environment in the ICU is high tech was described in all studies. Johnsson et al.
(2006) describe the respirator and the endotracheal tube as the single biggest reason
for discomfort. Patients' recollection of the ICU was bothersome they described it
as chaotic, with loud noises, whistling. They felt that many people were in the room
and many were talking at the same time. The technological apparatus monitoring
and ventilator, patients feel dependent and vulnerable (Löf et al., 2006).
7. Dreams and nightmares
The study participant were divided into three groups according to the type of
the dreams, many of them didn’t remember any kind of dreams, while the
minority were dreamed of hopeful pleasant dreams. we didn’t found previous
studies that match with this finding, although in our study it was shown that
those participant had experienced pleasant dreams of being cured and
discharged from the ICU and get back to a normal life, while about one case
experienced the nightmares, other patients hadn't any dream experiences, which
approved by the precious studies, the thing seem to be similar with the previous
research, which shown that: Surreal experiences, nightmares and fantasies are a
common occurring memory that patients recolleted from the time they received
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treatment for an ICU. These have affected the patients not only during the time
in the ICU, but also followed when the patient is sent on to the ward and affected
their lives long after they come home. Patients associated these experiences to
different situations, medications or treatment itself (Johnson, St. John & Moyle,
2006).
A long ICU stay and being admitted as an emergency increase the risk of
delusional memories (Samuelson et al., 2007) and these experiences are mostly
unpleasant and frightening involving bizarre nightmares (Johnson et al., 2006).
These bizarre recollections are often associated with negative emotional
outcome (Rattray et al., 2004, 2005), and this study illustrated such
recollections. Quantitatively assessing patients’ perception being mechanically
ventilated, in conjunction with assessment of anxiety, depression and
posttraumatic symptomatology may provide a way of predicting those who
might subsequently develop problems (Rattray et al., 2004, 2005). This is
important if we are to develop interventions which address such problems.
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4.3 Conclusion
To be dependent on other people and technical medical equipment for
survival creates a sense of being delivered into the hands of others, as the
people being mechanically ventilated could not trust their body to function.
Being connected to tubes and being unable breath or communicate oneself
are stressful, which is in line with the findings from previously studies.
Further research is necessary to determine their needs and the support will
be best for them.
4.4 Limitations
We would include 15 participants in our study, but from a practical
standpoint, we include only eight participants, it is because of the lack of
cases, but according to Georgi three cases is enough if they give a saturated
information.
Moreover, it was not good management of the interviews in the ICU area,
because the break was going on, got the nurses interrupting our conversation
to give medicine or to check vital signs, and newly admitted cases to the ICU
interrupted us.
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4.5 Recommendation
Awareness among caregivers to the particular plights of intubated
patients may help to alleviate some of the remaining discomforts. Among
nursing strategies to improve communication are anticipating the needs of
the patients and experimenting with a variety of augmentative
communication techniques to interact with the patient. It is recommended
that caregivers give timely, reliable, accurate and unambiguous information,
respecting the patients’ domain and individual time frames. Intervention
studies are needed to improve communication strategies and awareness of
human interaction.
4.6 Implications
The documentation and evaluation of patients' prior experiences, i.e. their
own experienced severity of their condition are of great importance in
understanding the patients' situation and need for providing individualized
nursing care; including 'true presence', empathy, and a caring relationship
between the patient and the nurse. The caring relationship provides a degree
of relaxation, safety and security and allows the patient to rest. When talking
with patients after they have regained consciousness, it is of importance to
be aware that their memories might be 'jigsaw puzzle memory'. This may be
difficult for the patients to describe, or they may even be ashamed of not
being able to remember properly, and thus reply that they 'do not remember
anything’.
Patients may also feel that these difficulties in thinking and recollecting
reflect some kind of mental instability due to 'brain injury' in conjunction
Page | 85
with the operation or the accident, and therefore do not want to talk about it,
as the possibility of this frightens them. But an open and mutually trusting
relationship between each nurse and patient would probably result in a
deeper insight into patients' memories and unreal experiences. This would
allow the nurses to explain to the patients that such experiences are common
during the treatment period, and that their intellectual capacity would not be
impaired, and would be restored.
The presence of other patients can also be frightening, as they can trigger
feelings and thoughts of death, or the unknown. Patients are, during their stay
in the ICU, defenseless and vulnerable. It is, however, often difficult to
assess immediately patients' emotional and/or mental conditions. The
awareness that it is important to avoid situations or activities which can
evoke fear is probably one of the most crucial factors. Caring relationships
can be essential in either resolving or increasing the effects of 'unreal
experiences' or feelings of confusion. It was found that the technical
equipment could also result in fear and thoughts about non-existence. It is
therefore of great importance that nurses explain what equipment the patient
is connected to and why, and how thing it is planned to be used. It is also
important not to use more equipment than necessary, as it seems to increase
patients' tension and fear. The patients' experiences of their 'strange' and
'empty' bodies are frightening.
Nurses can help the patients by explaining that the body perception will
return as they become more awake, and by assisting the patients to move
Page | 86
their arms, legs and head. If this is done, patients may start to feel a regaining
of control over their bodies, which encourages a return to reality. The nurses
must always remember that a patient is extremely vulnerable in this situation
and overwhelmed by feelings of fear and tension, and they must therefore
plan and implement nursing procedures and actions from this awareness.
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Chapter Five
Page | 88
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5.2 Annexes
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Annex I
Consent Form
The undersigned, ... ... ... ... ... ... ... ... ... ... ... (name), born ... ... ... ... ... ... ... ...
confirms to have read / been explained requests to participate in research project on
“The experience of the patient who was being mechanically ventilated in the
intensive care unit ”
I have been given a copy of your request / project orientation and are willing
to participate in the project. I have received both verbal and written information
about the study, and I m aware that my participation is voluntary. I am informed that
at any time, without having to explain it might withdraw from study if I wish. If
needed I can be contacted for a new interview or clarification of ambiguous
relationship.
... ... ... ... ... ... ... ... ... ... ... ... ... ..
(Date) (Signature of informant)
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Annex II
Title of the study
Experience of the patient who were being mechanically ventilated in the intensive
care unit .A descriptive phenomenological study
Introduction:
We are the students: Mostafa Salamih , Ahmad Dwaikat , Hamed Hantouli ,
Mohammed Al deriya in the Nursing Research project , a research study being
conducted at the An-Najah national university.
The purpose of this study:
Is to describe the reported ICU experiences of patients undergoing mechanical
ventilation, such certain experiences might be physiological, and psychosocial.
What you expected to do:
If you decide to participate in this research you will be asked freely to provide
information about what you have been experienced while you were connected on
the mechanical ventilator. Your participation will last approximately 30-60 min.
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Privacy:
All data are recorded only for the purpose of the study, and will remain held in a
locked cabinet during the study and destroyed after the study is complete. No real
names will be mentioned in the study and you will be identified by codes.
Refusals to participate \ withdraw from the study:
There is no obligation for you to participate in the study, you can refuse to
participate or withdraw from the study at any time, even without giving reasons
and this will never have a negative impact on you.
Benefits:
The data which will collect help to improve the health care by identifying patient
complains through the period of mechanical ventilation , and notify health team
about what the patients may feel and experience when the connected to mechanical
ventilator and increase the quality of care while introducing any of the medical
procedure based on patients’ experiences.
Harm:
No harm will come to you from participating, and your name will never be
mentioned to anyone, if you develop stress during our conversation you can
withdraw without any sanctions or you can postpone the interview until you get
better and, We appreciate your participation If after the interview still have
something to convey, we are ready for more clarifications at the following
telephone numbers:
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Student:
Mostafa Salamih: 0598065551
Hamed hantouli: 0598198008
Ahmad Dwaikat: 0597132094
Mohammad alderiya: 0599936536
Supervisor: Dr.Aidah Alkaissi :0597395520
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Annex III
Experience of the patient who were being mechanically ventilated
in the ICU - Interview guide line
Describe your experience of being mechanically ventilated in an
intensive care
1. What was your Emotional - Feelings, thoughts About Experience of
mechanical ventilation?
2. What was your reaction toward the mechanical ventilator?
3. What was the Specific actions around ventilator treatment that made you
feel well or good or discomfort?
4. Describe your Memory of hospital stay, communication, comfort, painful
experiences?
5. What was your thoughts, feelings about End respiratory therapy?
Describe the experience of care , nursing care in the ICU
1. What was your feeling toward self-care limitations, and to be
dependence?
2. How did you felt to participate / not participate in the decision making
process?
3. How can you describe the care which provided to you?
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4. What things was important to cope with the situation and promote your
health?
5. Preference will improve the care of people who was ventilated?
Describe your experience life before and after suffering from acute
illness or trauma
1. How was your Daily life?
2. Describe the feeling of your body in health and disease?
3. What was your experience at the Onset of the disease?
4. How does the illness affect your psychological status?
5. What has been the most difficult?
6. What was your feeling for losing the functional abilities?
7. How do you see the future?
How do you perceive the environment :
1. Lights , sounds of the machine , voice of the professionals
2. Equipment, tubes, mechanical ventilator?
3. Drugs that provided?
4. Bed condition?
5. What was your feeling from suction process?
6. Presence in the ICU?
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What about family support, relatives, friends?
1. Did your family used to visit you while you were mechanically
ventilated?
2. Did you feel of them when you were sedated?
3. How did that make sense for you?
Did you had dreams, nightmares, and surreal experiences?
1. What was that dreams show you?
2. How do you feel when these dreams shown up?
3. What things seem to play factor enhance their appearance?
4. What things was playing major role in alleviation of this dreams?
Finally, you have something to add?
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Annex IV