A multicase study of a prolonged critical illness in the Intensive Care Unit : patient, family and nurses' trajectories : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing, Massey University, Palmerston North, New Zealand

Abstract

A critical illness necessitating admission to an Intensive Care Unit (ICU) is a profoundly stressful event for patients and families. It is important nurses understand these experiences, to provide appropriate care. For most patients admitted to an ICU in New Zealand their stay is of short duration. However, as a consequence of advances in life-sustaining therapies a new group of patients has emerged. This cohort survives their initial critical illness but become dependent on live-saving interventions for a prolonged period, necessitating a protracted ICU stay. This purpose of this study was to explore the experiences of the patient, their family and healthcare professionals during the trajectory of a prolonged critical illness in an ICU. A qualitative instrumental multicase study approach was used, informed by the Chronic Illness Trajectory Framework. Data collection involved six linked cases (patient, family and clinicians) in four ICUs over a two-year period utilising observations, conversations, interviews and document analysis. Longitudinal data analysis revealed four sub-phases in the trajectory of a prolonged critical illness. These sub-phases were determined by the patients’ physiological condition, with each sub-phase also representing different psychosocial needs. The patients’ physiologically debilitated state made them prone to complications and added to the complexity of their illness trajectory. Families’ trajectory, dominated by uncertainty, were informed by the patients’ trajectory. Families worked hard to relieve the uncertainty by looking for signs of improvement. As their trajectory progressed the ‘wear and tear’ of prolonged uncertainty became more evident. Nurses’ work was informed by the patients’ trajectory, with different sub-phases representing different challenges. During the mid-phase, distress related to the uncertainty about positive patient outcomes and the suffering some patients endured. During the emerging with a failed body sub-phase, nurses were challenged to meet all patients’ needs due to their overwhelming work priorities. The identification of the specific sub-phases of a prolonged critical illness trajectory can result in interventions being targeted to each sub-phase to improve outcomes and experiences. Research and education can also be targeted to each sub-phase to explore specific issues and problems to continue to advance this body of knowledge.