INTRODUCTION

The intensive care unit (ICU) is a highly specialized unit, where medical and nursing staff with specialised skills provides treatment and care to patients with life threatening conditions (Patak et al. 2004). Patient’s physiological status is monitored continuously and special procedures and therapies, which cannot be undertaken in the general ward, are carried out in this unit (Stein-Parburg & McKinley 2000). Venti-lated patients who require intensive care unit (ICU) treatment may encounter unpleasant experiences. These expe-riences may include factual incidents and delusional memories of ICU such as dreams, hallucinations and frightening experiencesapart from their ongoingmedical or surgical illness (Patak et al. 2004; Bergborn-Engberg & Haljamae 1998). These experiences have been known to prolong their rehabilitation, leading to poor recovery. Survivors of critical illness from ICU with differing presenting diagnoses have reported phy-sical and psychological problems during their recovery (Jones et al. 2003). Moreover, Rattray et al (2004) & Patak et al (2004), reported that patients who required ICU had untoward experiences lasting well beyond the physical recovery of their illnesses. These incidents may include factual or delusional memories of their ICU stay, and these are usually reported as dreams and hallucinations.

The sources of stress on patients in ICU include health care providers themselves, visitors, and environmental factors such as noise, lightning and procedures. Some frequently cited factual memories en-countered in ICU and perceived as stressors to the patients are: tracheal intu-bation, extubation, endotracheal suctioning and physiotherapy. Although, these memo-ries may be worsen by illness, judicious use of sedation can overcome these pro-blems (Roberts et al. 2007).

Patients admitted into the ICU can broadly be divided into two types. Some patients are admitted as emergencies such as after a cardiac arrest or major trauma e.g. road traffic accident. On the other hand, admission would be planned for example, after surgery or as a result of an existing medical condition that has deteriorated and needed respiratory support, close monitoring and drug infusions. There may be differences in the level of adaptation between the two types of patients. Pre-admission information, which can be given to patients for “elective” admission to the ICU, provides a way to achieve better adaptation, while such benefit is not available for an emergency admission (Cornock 1998). For an emer-gency admission, the patient usually expe-riences higher level of stress and anxiety due to a sudden change of environment and unavoidable traumatic encounters (Strahan et al. 2003). It can be judged from a nurse comment as cited by Bergbom-Enberg & Haljamae (1998)“even as long as four years after respirator treatment, most patients (90%) who remembered their treatment still recall the situation as unpleasant and stress evoking” that patients often regard ICU as a place that is unpleasant and dreadful. According to Stein-Parbury et al (1990) mechanically ventilated patients face many barriers in their communication needs. Inability to communicate with others results in unrecognized pain, feelings of loss of control, anxiety, fear, distress, frustration and depersonalization. Tracheal intubation is often being regarded as the number one problem causing communication difficulties (Roberts et al. 2007).

Bergbom-Enberg et al (1998) retro-spectively interviewed 158 patients who were mechanically ventilated from 2 to 48 months and recorded their recall of experiences during their ICU stay. Appro-ximately 50% of the patients were able to remember the experience of being ventilated and most recalled the situation as discomforting, stressful, feelings of anxiety, fear, agony, panic and insecurity. Similarly, Roberts et al (2007) concluded that the inability to speak was identified by all respondents as causing distress such as pain and discomfort from endotracheal tube, suctioning. Other distresses were inability to orientate to time and the intolerable amount of noise. These distressing factors can be aggravated by the health care providers themselves in the delivery of care. Most of the time, the nurses failed to address the patients’ specific physical and emotional needs because of communication problems (Scragg et al. 2001).

According to Roberts et al (2004), over one third of patients have some degree of factual memory related to mechanical ventilation, especially suctioning and removal of the endotracheal tube. Stein et al (2000) stated that factual recall of traumatic incidents e.g. endotracheal tube suctioning may protect patients against anxiety and panic attacks after ICU discharge. Traumatic memories from the ICU such as hallucination may leave patients vulnerable to anxiety, depression, and panic attacks and most feared of all, post traumatic stress disorder. Patients frequently admitted that these memories as extremely vivid and real. Some patients tried to block recall of these traumatic memories and accept them by making them intellectually meaningful (Scragg et al. 2001). Incidental events such as viewing a hospital, future episodes of seeking treatment at hospitals and watching television programs, may cause them to become overwhelmed by the feelings and physiological arousal that can result in depression. Chan (1990) reported similar findings. However, all memories of ICU may not be negative and stressful. Rattray et al (2004) interviewed 109 patients and found 80% of them rating their care as good, over 50% of the respondents reporting that they felt safe and 40% never felt scared while being treated in ICU. Scragg (2001) found that the presence of a caring relationship either by the nurses or family members can have a positive impact and decrease the level of fear whilst in ICU.

As most studies in literature series were undertaken in the West, there is limited localdata on patients’ recollection whilst being mechanically ventilation in ICU. The objective of this study was to investigate recollections of artificially ventilated patients at ICU of HUKM. This study will add on to the body of evidence regarding recollection expressed by mechanically ventilated and the actual level of frustration among our local patients whom by far, are different in demographic and socio-economic entities in comparison to the West.

MATERIALS AND METHODS

A cross sectional study was conducted in ICU of HUKM from January to March 2006. Data collection was done using a structured “Intensive Care Experience Questionnaire” (ICEQ) adopted and modified from Rattray et al (2004) which consisted of four domains: awareness of surrounding; frightening experiences, recall of experience and satisfaction with nursing care. There were three sections in the data collection form; section A: comprised of 30 questions using Likert scale 0-2 (0-never, 1- some of the time and 2- all the time) to measure what patients felt and remember about their experiences whilst during their ICU stay; section B: 31 questions using Likert scale 0-3 (0 - not applicable, 1 - not stressful, 2 - a little stressful and 3 - very stressful) to measure patients recollection of stress experienced during intubation and on mechanical ventilation in ICU. Section C consisted of demographic data of the patients including patient’s age, gender, level of education, marital status, occu-pation, monthly income and length of stay in ICU.

Inclusion criteria were: age more than 21 years, ability to orientate to person, place, time and situation at time of data collection, competency and ability to sign an informed consent and requirement of intubation and mechanical ventilation for at least 18 hours with extubation within the previous 72 hours at time of interview. A convenience sample of 45 patients from ICU who met the inclusion criteria were recruited for this study. These time frames were chosen to provide a sufficient amount of time required for the patients to recall their experience while being mechanically ventilated after extubation. Patients were excluded if they had: neurological complications; psychiatric problems, tracheostomy and heamo-dynamic instability at time of data collection. The study was approved by the ethics committee of Universiti Kebangsaan Malaysia, Faculty of Medicine (FF-199-2005) and permission granted from the Director of Hospital Universiti Kebangsaan Malaysia. An illustration of the attributes of this study, as a conceptual framework is shown in figure 1.

RESULTS

Demographic data of respondents are presented in table 1. From the findings of 45 participants, 20 respondents (44%) were aware of their surrounding while 25 respondents (56%) were unaware of their surroundings. However, 31 respondents (69%) reported frightening experiences. In the recall of experience domain, 39 (87%) respondents had actual recall, whereas 6 (13%) respondents were unable to recall their experiences. A high proportion: 43 respondents (96%) reported satisfaction with the delivery of nursing care and only 2 respondents were unsatisfied (figure 2). There was positive correlation between awareness of surrounding and their abilities to recall their experiences (p<0.05). Patients’ awareness of surrounding shows the strongest statistical significance; a unique contribution to the prediction of their abilities to recall their experiences with beta coefficient value 0.353 and p<0.05.

DISCUSSION

This study revealed that mechanically ventilated patients were aware of their surrounding during ICU stay and able to recall their frightening experiences. They were aware of what was happening to them though they were sedated.These factors are similar to those identified by other studies (Roberts et al., 2007; Scragg et al., 2001). To protect patients from these harmful factual memories during their ICU stay, nurses should be aware of the need to communicate adequately and respect patients’ rights to dignity and information even though they were on sedation and relaxant. However, Armondo et al (2002) reported that severely ill patients on prolonged mechanical ventilation are likely to be paralyzed and heavily sedated, may suffer from short term loss of memory and may not be fully aware of their ICU surrounding. However, more severely ill patients tend to have poorer recall of their ICU stay.

More importantly, nurses should be more diligent and committed in delivering nursing care to ventilated patients in ICU. Nurses may be able to reduce the stress asso-ciated with endotracheal tube suctioning by providing prior explanations to patients of what they may expect and be gentle during the procedure. They can identify inade-quate levels of analgesia and sedation by assessing patients’ reactions to the endotracheal tube suctioning. The role of nurses are to help monitor the patients while the anesthetists are responsible for the other management of the patients such as prescribing anxiolytic drugs to reduce patients’ anxiety, analgesics to reduce pain and also the use of sedatives to increase comfort and improve sleep. A better under-standing of the recollections of traumatic events and stressful experiences reported by patients could allow nurses to better anticipate in patient care and improve their quality of life during ICU stay (Strahan et al. 2003).A large number of patients have predicaments in verifying their perceptions and cope with fears, anxiety and stress through verbal communication (Scragg et al. 2001).

This study adds new information about the relationship of satisfaction between mechanically ventilated patients and the nurses. Our findings further support pre-vious studies by Johnson & Sexton (1990), who stated that, nurse-patient relationship in ICU is deemed to have the power of reducing patients’ frustration and dissatis-faction. However, when ventilated ICU patients’ feelings are unmet due to the inability to communicate adequately with nurses, these could aggravate anger, discomfort and anxiety. This will sub-sequently lead to a prolong rehabilitation and poor recovery that exacerbate physical and psychological disability (Rattray et al., 2004).Several studies also revealed similar findings on patient’s feelings and experiences related to anger, discomfort and anxiety when they are unable to com-municate effectively (Bergborn-Engberg et al., 1998). According to Roberts et al. (2007), some patients may be unwilling to talk about their bizarre and unreal expe-riences for fear that others may judge them to have mental instability.

It was found in this study that patients’ awareness of surrounding was the strongest factor statistically and was a unique contribution to the prediction of their abilities to recall their experiences. However, Strahan et al (2003) reported that frightening memories, for example, hallucination or nightmares are potential threats to patients’ psychological recovery. Patients discharged from ICU needs to have an opportunity to discuss their memories and nightmare as a way to overcome the hurdles to recovery.  Consequently, patients should be explored about their unpleasant memories to prevent residual psychological distress, which can result in poor mental health (Jones et al., 2003).

CONCLUSION

The finding of this study permits nurses to see the problems of mechanically ventilated patients through reports of unpleasant recollections by the patients themselves. Patients reported frustrations in their attempts to make their needs known. Although they are on sedation and relaxant, they are aware of all unpleasant events occurring in the ICU. This infor-mation offers insight into the needs to alleviate patients’ unpleasant experiences and what the nurses can do to help mechanically ventilated patients.

ACKNOWLEDGEMENTS

I sincerely would like to acknowledge the support of many people especially Asso-ciate Prof.Choy Yin Choy and Dr. Noorfaizan Saaidin for their contribution in this study. My special thanks go to intensive care staff and patients of HUKM for granting permission to conduct this study.