Received: 14 Apr. 2009
Accepted: 10 May. 2009
Original Article
Patient's experiences of mechanical ventilation
Akram Arabi*, Khosrow Tavakol*
Abstract
BACKGROUND: Endotracheal or tracheostomy tube in mechanically ventilated patients disturb verbal communication
with others. Therefore, patients are frustrated of requesting for their needs or problems related to artificial breathing.
Therefore investigating self-experiences of these patients can be applied in providing them with a better care by clinical
personnel.
METHODS: This is a qualitative phenomenological survey. The study population was patients who were mechanically ventilated at least for one time and were more than 12 years old. Data were collected during five months by deep interview and
then were analyzed by Collizi's seven–stage method.
RESULTS:
The findings of this research were classified in 139 codes and 3 categories as: 1) Interpersonal experiences, 2)
Extra personal experiences and 3) Intrapersonal experiences.
CONCLUSION: Mechanically ventilated patients tolerate many stressors, which many of them are externally sustained. Better care will reduce these stressors, and make it easier for the patients to get along with the artificial breathing. Meanwhile
some pleasure experiences had been mentioned by patients in this study.
KEY WORDS: Experiences, mechanical ventilation, patients.
IJNM R 2009; 14(2): 83-88
M
ost researches conducted in the field
of mechanical ventilation (MV) have
focused on the promotion of the device's functional quality, lengthening the life
span and enhancement of cardiopulmonary
function.
On the other hand, few researches have investigated the experiences of the patients who
had undergone mechanical ventilation. Although, it could be the same as the patients who
undergo chemotherapy or hemodialysis, it
makes more problems among the patients under ventilation as they cannot communicate due
to tracheal tube or tracheostomy as far as they
are under these procedures.
There are controversial ideas regarding mechanical ventilation experiences. Some believe
that the patients should be thankful. In fact,
they believe surviving a disease is adequate and
investigating the patients' experiences is something extra. Meanwhile, there are opposite ideas
in this regard. Thelan et al1 (1990) explain:" According to Griess and Frensler, although it sustains life, mechanical ventilation constitutes an
environmental disturbance and therefore constitutes a stressor. The personal feelings that patients associate with the experience of mechanical ventilation influence their reactions and
their ability to reconstitute or reach a steady
state."
Tracheal intubation is an acute stressful
event. Researchers found no specific relationship between the duration of intubation and
stressors reported by patients receiving mechanical ventilation. The number of stressors
reported in patients was the same for both
short- and long-term mechanical ventilation.2
*MSc, Department of Operating Room Nursing, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran.
Correspondence to: Akram Arabi MSc.
E-mail: aarabi@nm.mui.ac.ir
Research Article of Isfahan University of Medical Sciences, No: 83475
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Cook et al3 say if clinicians understand the
lived experiences of patients, they can better
appreciate patients needs during the weaning
process, and by inference their role as clinicians,
during weaning from mechanical ventilation.
Besides patient's experiences, some suggestions can be made for ICU team that can open
new wider horizons toward understanding patients' expectations.
Mechanical ventilation is vastly administrated for critical patients. In Iran, the increasing ratio of open heart surgeries and high number of head injury cases due to car accidents in
addition to respiratory problems have made
more demands for this procedure. It is so that
each year many patients undergo mechanical
ventilation due to various reasons while the
treatment team has no live evidences documented about patient's experiences.
Personal, educational and clinical experiences of
the researcher show that what has been conducted for these patients up to now has been
taking care of the patients, sometimes sympathizing with them and finally asking them for
more cooperation during ventilation process.
The patients have rarely been listened to reveal
their own experiences while being under ventilation.
What nurses as health providers do is a series of routine and stereotyped activities. How
much they can help the patients to cope with
ventilator more comfortably is being questioned
itself. Vast usage of this treatment method and
staffs' unawareness concerning patient's experiences imposed the researcher to collect these
experiences in order to be able to take care of
them with a new approach from this time on.
The purpose of the present study was to investigate patients' experiences concerning mechanical ventilation.
Methods
This is a qualitative design since this sort of research fits well to detect people's experience on
a specific phenomenon.
The qualitative research is a way to gain insight through discovering meanings. Within a
holistic framework, qualitative research is a
means of exploring the depth, richness, and
complexity inherent in phenomena. From this
process, meaning is produced. However, because perception varies with the individual,
many different meaning are possible.4
This is a phenomenology design focusing on
getting the structures of human experienced
phenomena through the analysis of verbal explanations from the viewpoint of the participants. The population studied comprised the
patient's undergone mechanical ventilation. Inclusion criterion was to undergo the procedure
at least once as well as age over 12 years and the
desire to attend the interview. The sampling
method was purposeful and included eight participants.
The study was carried out through interviews in the hospital for 5 months in 2005 on
patients with inclusion criteria and history of
mechanical ventilation in any hospital yard or
at their homes in Isfahan.
The mean length of interview for each participant was 20-40 min. All the interviews were
recorded and the participants were coded based
on the time of their interview respectively.
In qualitative studies, the term validity refers
to the extent to which the research findings
represent reality.5 In these studies, validity is
the credibility of description, conclusion explanation, interpretation, or other sort of account. It
is the extent to which the findings of a study are
true, and whether they accurately reflect the
aim of the research and the social reality of
those participating in it.6
In the present study, as the data were being
collected by open interviews with the patients,
it has been tried to direct the participants just to
express their own experience from mechanical
ventilation.
In qualitative research, reliability is defined
as the measure of the extent to which random
variation may have influenced stability and
consistency of the results.5
In the present study, the researcher has tried
to collect the data carefully and patiently and
avoided any possible feedback. She has tried to
use the participants who could remember their
memories and yield important information. In
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case of any deficiency in collection of data, the
researcher has indicated to the item again to
complete the data yielded by the participants.
Since, the seventh step of Collizi's method is to
refer to the participants again to be sure about
the collected codes, reliability of the data was
considered. It is indicated that all extracted
codes and concepts obtained from the codes
were studied and confirmed by someone else.
The data were analyzed by Collizi's seven-stage
method.
Results
There were 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. Four of participants had high school
diplomas, 3 less than high school diploma and
two were illiterate.
The reason for ventilation was Guillain-Barre
syndrome, Myasthenia Gravis, traumas and
anesthesiology complications.
The results were obtained by Collizi's sevenstep method. At the first step, the researcher
carefully listened to the recorded tapes, wrote
down the statements, and managed to share the
feelings with the participants. At the second
step, the researcher extracted the key words and
sentences related to the under study phenomena as an important part of the work. At the
third step, the researcher started to form the
specific concepts for each extracted sentence
and finally 139 codes were extracted from participants' remarks, for example: "feeling the
death", "ambivalence in presence of accompanying person" and "good feeling after administration of suction".
At the fourth step, the concepts were classified in subject specified categories (formation of
themes or sub concepts). For instance, the concept of "changes of physiologic needs" that itself
includes themes of "feeling thirsty, hungry, suffocated, etc". At the fifth step, all extracted concepts were presented as a comprehensive and
complete description. They included main
themes or concepts. In the present study, three
main concepts were obtained from patients' experiences categorized as intrapersonal, extra
personal and interpersonal experiences. Intrapersonal experiences were experienced when
patients had no other stimulation except for
connection to the mechanical ventilation. This
concept comprises sub concepts obtained from
patients' descriptions in the mentioned situations. Some of intrapersonal experiences included: "coping with present condition",
"changes in self image", "loneliness", "pain and
lack of peace", "fear from sleep", "unfamiliar environment" and "changes in physiological
needs". The second group, extra personal experiences, were experienced when patients were
sustained other stimulations in addition to their
connection to mechanical ventilation, such as
"suction", "change in position", "chest physiotherapy", "personal health", "change in sleep
pattern", "weaning", "inspiration by Ambo" and
"vital dependency to IV medication". The third
group, interpersonal experiences, was experiences that the patients under ventilation had
toward others. They included "communication
deprivation", "communication by writing", "one
way verbal communication" and "touch", which
the patients experienced toward physicians,
nurses and their accompanying persons.
Discussion
According to the findings of this research, the
patients undergone mechanical ventilation have
different experiences at the time of connection
and weaning which most of them are stressful
and imposed to them from the outside environment.
Some participants' remarks show how they
have accepted their present situation. This fact
reflects that some of them have inevitably accepted their present condition, whereas, some
have well coped with that and hopefully passed
their disease. Disease acceptance by the client
drives them toward hospital admission, acceptance of procedures and possible operations.
In this study, some participants have expressed the remarks showing a change in their
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self-image. For example, one patient said: my
face had looked like a monkey. Kim et al2 also
have indicated that the patients expressed "uselessness" as experiences of Mechanical Ventilation.
Two other participants in the present study
have reported "being in an unfamiliar environment". Their remarks showed that although
they both have expressed an unfamiliar environment as a clear experience, this environment
has been stressful to one but a new and exciting
to the other. This difference can be due to their
different ages and gender since one has been a
20-year-old girl whiles the other a 13-year-old
boy.
One of the participants indicated sort of general and dull pain. There are no further findings
regarding general pain mentioned by other participants. Some complained of pain in throat or
incision site .There was not such an experience
(general or local pain) mentioned by the patients in literature review. That can be an unpleasant feeling due to connection to the device.
Another group of patients' experiences has been
categorized in the present study as the theme of
"physiological needs". In fact, connection to the
device has caused some participants to feel suffocated, hungry and thirsty. Kim et al2 express
"the feelings of loss of control" indicated by the
patients. Some participants reported experiences such as "dried throat", "feeling of cough"
and "uneasy endotracheal and tracheostomy
tube" which categorized as the theme "lack of
peace" by the researcher in the present study.
Patient's needs concerning emptying their tracheal cuff seem different. Some need it to be
done in less than two hrs and others need it to
be kept emptying for a longer period. In other
researches, "lack of peace" has been indicated as
a negative and unpleasant experience but in a
different manner. For example Kim et al2 indicate "the feeling of being tied down by equipment and feeling of gagging."
The participants had various experiences
concerning loneliness. Except for one who
found it pleasant, the others indicated that as
intolerable. A 20-year-old female participant
indicated:" I liked to be alone, because I didn't
like to be manipulated by anyone". In the other
hand, a 43-year-old female participant indicated: "I liked my nurse to be with me as long as
possible. Whenever I was left alone, I thought a
hazard will be occurred soon". Engoren & Scott7
in a phenomenological study on patients undergone prolonged mechanical ventilation reported: "According to the participants they
prayed a lot every day either in private or with
family members." Cook et al3 reported loneliness as "fear of abandonment by staff," indicated by the patients, that is just after weaning
from mechanical ventilation. Various patients'
experiences concerning loneliness in the present
study can be because patients’ experiences have
been investigated from their connection to
weaning from mechanical ventilation but not
just after weaning.
The second group of experiences in the
present study is extra personal ones, experienced by the patients from outside stimulation. One of these is indicating "sleep disorders"
in the present study. Sleep disorders have been
categorized in two concepts. One is the "fear
from sleep" (they think they die when they
sleep) indicted in intrapersonal experiences and
the other one is "change in sleep pattern" (in
coordination between patients' sleep with
nurses' working shifts) indicated in extra personal experiences since it originates from outside stimulants. Cook et al3 in a research on 43
patients undergoing mechanical ventilation,
have recorded sleep disorders among patients'
difficult experiences. She reported: "Although
patients received no sedation for 45 hrs, many
could not recall distinguishing between night
and day. they reported being confused during
weaning .Patients felt as thought their locus of
control was external to themselves, reflecting
the intense dependence they have on the ICU
team and on family members."
In the present study, although, the patients
have not used word of "locus of control", they
had relatively similar comments on that.
Yielded from patients' experiences, they
claimed that the factors of in coordinated sleep
time are those controlling their sleep from outside their body. Therefore, the patients had no
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self-control on their sleep. This can mean similarly for a patient with fear to sleep since they
think "sleep is equal to death". Therefore, sleep
control point was also outside their body and
what they have self-control on it is to control
death by not sleeping instead of controlling
their amount of sleep. Regarding the obtained
results, it seems that making coordination between patients sleeping time and nurses' work
is a crucial need for the patients. This can be
almost achieved by modification of routine care
time based on patients' needs.
One part of patients' experiences in the
present study was about their experiences on
suction. High number of complaints about suctioning as a stressful item reveals a serious need
for investigation to lower patients' physical
problems related to this procedure. One of the
participants explains that self-suctioning is
more pleasant compared to that administrated
by a nurse or by the accompanying person.
Nurses should possibly take this issue under
close attention to lower the invasion of this procedure. Thelan et al1 say: "According to Griess
and Frensler negative experiences reported by
the patients undergone mechanical ventilation
are due to extra personal stressors of endotracheal tube and weaning."
One of the other extra personal experiences
in patients with MV in the present study was
the effect of "patients' position change" as an
external stimulation. The point taken from participants' indications is that patients' need for
position change varies from one to another. The
shortest interval for position change in Iranian
hospitals is two hrs while one of participants
needed a rather shorter interval and another
one needed a longer one. Meanwhile, this interval for other participants has seemed appropriate with any length.
Another extra personal experience in this
study has been for chest physiotherapy. Patients'
suffer due to physiotherapy seem to be lowered
by explaining physiotherapy procedure and its
benefits to the patients as well as their pain relief
before beginning physiotherapy.
Ergoren and Scott7 in their research on patients with prolonged MV have named a group
of experiences as the theme "traumatic experiences."
Another external stimulation affecting MV
patients in this study is related to their personal
health. The procedures include sheets change
and patients' bathing. The only unpleasant feeling among the participants is for washing the
head that seems to be due to care provider's
function. This feeling can be changed by modification of this procedure. In general, those patients passing the steps of disease acceptance
and being aware of their role as a patient better
accept some procedures such as position
change, chest physiotherapy and personal
health.
In this study, the expressed experiences related to "medication" are in two groups. One
group is related to nurses' function in medication (presented in experiences related to "sleep
disorders" as this function disturbed patients'
sleep) and the other one is related to the medication substance entering their body. As indicated before, Cook et al3 extracted the phrase
"locus of control". In the present study, some
patients' feeling toward medication is close to
this way of expression. In the other words, for
some patients, the medication infused was vital
and considered as the outside control point. So
that the patient felt their locus of control dependent to medication.
One of the other extra personal experiences
obtained by this study is patients' experiences at
the time of weaning from MV. This liberation is
due to either weaning or lack of electricity. So,
at this part, patients' experiences concerning
Ambo as well as extubation have been presented. Cook et al3 in her study on MV patients
about their experiences at the time of weaning
reported: "Patients have expressions such as I
breathe to live or I can't order my brain to
breathe." She mentioned the weaning experiences as "frustration, hopelessness, fear, and
lack of mastery". The findings of the present
study as well as literature review concerning
weaning from MV show that these experiences
are mostly stressful and unpleasant.
The third general concept obtained by this
study is interpersonal experiences. One of the
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patients' experiences in this regard is communicational problems expressed through numerous
words by the patients categorized as the theme
"communicational deprivation" in the present
study. The great part of the expressed experiences is patients' communication with nurses.
Another part of them is about communication
with family members and friends and a minor
part is about communication with the physician. Thelan says: "According to Griess and
Frensler, both sensory and procedural information must be provided by the nurse to the patients, and a mechanism for the patient to communicate must be established."1
Kim et al2 claimed "intubation and communicational problems caused by MV brings about
deprivation that is counted as a great stressor."
One of the common communicational experiences expressed by the patients in the present
study is lack of explanation about treatment
procedures by the nurses toward them. Kim
(1999) says: "Investigators consistently have reported that objective information or sensory
information helps patients cope with and reduce psychological stressors."2
The participants have indicated their written
communication with their physician as a very
pleasant experience.
Another interpersonal experience in the
present study is patient-nurse relationship or
patient–accompanying person relationship
through touching. Engoren and Scott7 in their
research on prolonged MV patients reported:
"Another participant recalled an incident where
her grandfather, whom she referred to as her
guardian angel appeared at the bedside. She
believed that he was there to help her and insisted that he pulled her through this traumatic
event."
At the sixth step of Collizi's method, the researcher has summarized a general description
to a real and necessary structure. A little part
has been presented in the following: "Patients
acquire lots of experiences after beings connected to MV. Many of them are unpleasant
and stressful but besides these, there are yet
pleasant ones."
At the seventh step of Collizi's method, the
researcher has referred to the participants in
order to reveal the theory and inferred concepts
and she will send the research results to head
nurses taking care of these patients.
In the end, patients' suggestions to health team
have been collected as followings:
1) Explain more about ventilator.
2) Tell us what they expect us to do, how not to
breathe and how to breathe.
3) We can cope with the device better, if they
explain more.
4) Feel friendlier with our accompanying persons.
5) Do not judge instead of us.
Finally the authors declare that have no conflict of interest in this study and they have surveyed under the research ethics.
References
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Philadelphia: Mosby; 1990.
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before cardiac surgery. American Journal of Critical Care 1999; 8(2): 118-26.
3. Cook DJ, Meade MO, Perry AG. Qualitative studies on the patient's experiences of weaning from mechanical ventilation. Chest 2001; 120(suppl 6): 469S-73S.
4. Burns N, Grove SK. The practice of nursing research: conduct, critique and utilization. 4th ed. Philadelphia:
W.B.Saunders Company; 2001. p. 6.
5. Dempsey PA, Dempsey AD. Using nursing research: process, critical, and utilization. 5th ed. New York: Lippincott
Williams & Wilkins; 2000. p. 135.
6. Holloway I, Wheeler S. Qualitative research in nursing. 2nd ed. London: Wiley-Blackwell; 2002. p. 252.
7. Arslanian-Engoren C, Scott LD. The lived experience of survivors of prolonged mechanical ventilation: a phenomenological study. Hearth & Lung: The Journal of Acute & Critical Care 2003; 32(5): 328-34.
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