Table of Contents
Theme 1. Emotional expressions regarding the COVID-19 intensive care experience
In this study, the positive experiences of the participants regarding the intensive care unit were mostly focused on the interest shown to them. Negative statements and experiences were mostly determined to be respiratory distress, fear of death, nutritional distress and insomnia. Studies have shown similar results to the results of this study. Respiratory distress caused by COVID-19 can affect psychotic conditions that may develop in the patient and trigger death anxiety14,15. In their study, Zaybak et al.16 found that among the intensive care stressors experienced by patients, the primary ones were "pain", "fear of death" and "hearing the sounds that indicate heart problems from heart monitoring". Hintistan et al.17 found that intensive care patients had many bad experiences. Disease is a bad experience in itself. In addition to this experience, a sense of helplessness can accompany it. The intensive care unit, which is equipped with devices that make complex and strange noises, does not allow sunlight to enter and you can see every movement, which can cause anxiety. Poor experiences in an intensive care setting can only be minimized by the quality of care provided to patients.
Theme 2. Coping methods
In this study, the participants stated that they coped with the negative emotions they experienced during the intensive care process with the support of healthcare professionals and their families. These results are consistent with the literature. Sahoo et al. (2020) stated in their qualitative study that a patient tried to reduce his anxiety and concerns by praying18. In a study, people who experienced COVID-19 turned to religion as a coping strategy19. In a study on religiosity during the pandemic, there was a 50% increase in Google searches on prayer-related issues compared to before the COVID-19 pandemic20.
Belief systems are the most frequently used method in the fight against disease as well as many problems. Spiritual care strengthens the immune system and enables patients to cope with stress and shorten the disease process1. Situations encountered by the patients and determination of the methods of coping with the disease can be determinant in the support and service systems to be offered to the patients. Psychological support, drug support and spiritual support for those who request them are primary ones that come to mind in this sense.
Theme 3. Analogies
There may be some situations that are difficult to explain in daily life. In these cases, thoughts can be expressed more easily by comparing one concept to another21. Therefore, in this study, participants were asked to make a metaphor to describe COVID-19 and nurses.
For COVID-19, the participants used analogies such as "flu", "monster", "a stopper in the liver", "wolf in me", "tornado", "death", "haul", "Grim Reaper", and "bag in the head". As can be understood from these analogies, the worst experience of COVID-19 patients is not to be able to breathe.
The participants were asked to make an analogy to better understand what they thought about the nurses who spent the most time with them during their stay in intensive care units. As a result, the participants made analogies such as "angel", "family member" and "ladybug" for the nurses. One participant stated negatively with the definition of "sergeant" and the other with the definition of "being in hell". Positive descriptions are often heard in simulations in daily life. In the studies conducted, nurses mostly described themselves as "mothers", "superhero", and "saviors"22,23. Negative descriptions may be due to a disruption or nonfulfillment of something desired.
Individual evaluations are made with the effect of emotional states or reactive approaches that occur in instant situations. In fact, both negative analogies belong to the participants who have experienced intense physical restraint and panic attacks. Some participants stated that nurses sometimes respond late to patient requests. This may be associated with the nurses' workload, lack of staff due to the pandemic and problems with time. There are studies showing that nurses who care for intensive care patients are worried about getting sick or being a carrier and have dilemmas about their practices in intensive care units24,25,26,27. The problems experienced by nurses can also negatively affect nursing care. For this reason, the psychosocial health of nurses should be assessed and hospital management should provide support systems.
Theme 4. Attitudes towards the care provided
Considering the participants’ experiences on the care provided, the titles of respiration, nutrition, excretion and privacy, sleep and communication come to the fore. Swallowing and respiratory distress cause malnutrition in COVID-19. Stopping oral intake during treatment may cause malnutrition. Malnutrition, which affects mortality and morbidity rates, is seen in between 30 and 40% of intensive care patients28,29,30. A participant stated that he/she lost 25 kg in this study, which supports this situation. Sixteen participants stated that they had problems with nutrition for different reasons. It has already been demonstrated that malnutrition delays healing times and increases hospitalization periods. Therefore, the prevention, diagnosis, and treatment of malnutrition must be regularly included in the management of hospitalized COVID-19 patients in a rehabilitation department, to improve both short and long-term prognosis31,32. Studies clearly show that people have problems with nutrition, whether they are diagnosed with COVID-19 or not33,34,35.
In the present study, the participants stated that they were ashamed of having their clothes removed during the diaper change and due to their presence in the intensive care unit. Intensive care patients may not be able to protect their privacy for cognitive and physical reasons. It is the moral responsibility of healthcare professionals to protect the privacy of these patients. Health professionals should behave in the best interests of patients who cannot make decisions about privacy. If the patient's privacy is given due attention, the negative effects of the stressor on the disease can be reduced by eliminating the patient's concerns36.
Sleep quality is important for maintaining a healthy life and cell regeneration and shortening the duration of the disease due to its recovery. Insomnia directly affects the prognosis of the disease37. Normal sleep patterns and habits of the individual change completely in the intensive care. Intensive care units are clinics where a healthy sleep rhythm cannot be achieved due to their physical structure as well as routine and emergency applications to patients. In addition to arranging the environment to allow patients to sleep, meeting the habits of individuals even at a minimum level (for example, wearing a thin hospital shirt or underwear) can facilitate falling asleep. A participant said, “As per the intensive care conditions, you should not wear anything. The room makes you feel bad. I wish something could be arranged for the patients. I think that patients who are conscious can feel better then…”(P23). Tanrıkulu et al. (2022) reported that a patient expressed insomnia problems in a case they examined38.
Communication in intensive care is one of the most basic nursing skills. Patients with intubation or tracheostomy have difficulty in communication. Communication problems can cause stress, fear and panic in patients. Trust-based communication with the patient can help reduce the patient's anxiety, confusion, and anxiety. Studies have shown that nurses do not communicate adequately with unconscious patients39,40,41. In a study, Ashworth showed that nurses lacked conveying subjects such as time, day and date, which are the simplest examples of communication, to patients42. In this study, patients stated that nurses communicated with them and mostly used positive expressions to cheer them up. This difference shows that the holistic approach in the nursing profession has reached a preferable level. Some of the participants stated that they were concerned about their relatives. Seven participants stated that they could not see their relatives during the period when they were hospitalized in the intensive care unit, while the others stated that they had the opportunity to see their relatives from a distance or from the glass partition by taking protective measures. Those who saw their relatives stated that their negative emotions decreased and their strength to fight against the intensive care environment increased. In general, there have been visitor restrictions in many clinics and intensive care units to reduce the risk of transmission of COVID-19. In a study, communication through phone and video calls was approved due to patient and visitor restrictions during the COVID-19 pandemic43. It is important to provide family-centered holistic care to accelerate the recovery of patients44. Being able to see their relatives for a few minutes or hear their voices can eliminate the feeling of loneliness that can reduce the patients’ anxiety. Therefore, it is useful to review the visit and interview procedures in the intensive care unit. Although individualized practices are on the agenda, the principle of justice should be applied in patient visits as in every area and every patient should have the right to be visited. On the other side, visiting a patient hospitalized in the intensive care unit can be unsettling and frightening for the relatives of the patient due to the risk of transmission. However, it should not be forgotten that the relatives of the patient take the risk of visiting despite all kinds of risks due to the fear of losing the patient without seeing or even touching him/her for the last time. Restrictions set for protection may cause lifelong regrets. In fact, the positive statements of the participants who were visited confirm this idea.
Limitations
In this study, we interviewed patients discharged from the COVID-19 intensive care unit. However, there are some limitations to this study as well. The results cannot be generalized since the study was conducted in a single region. Another limitation is that we asked the patients about their past experiences after they were discharged. Retrospective assessment may not be 100% accurate as time intervenes. There is also a limitation in this manuscript with the degree of depth that has been reached in the analysis that has been merely descriptive.
