Kb Diary 8 Instrumental
Stayce Cawthorn
The BBC National Orchestra of Wales is midway through an ambitious tour of Argentina, Chile and Uruguay, including a community residency celebrating the 150th anniversary of Y Wladfa, the Welsh settlement in Patagonia. Harpist Catrin Finch kept a diary of the first week of the residency
''Twas the week before Christmas and all through Santa's workshop were busy elves. Among them is Leon, an ornery elf who turns to his diary to cope with each difficult day. Combining humor ous prose with favorite carols, this creative holiday work will be the best gift your audience ever received! From wooden soldiers who break rank and fight to defective reindeer harnesses that accidentally come with cowbells, this work is sure to delight! Perfect to feature an administrator or student as narrator. Easy to put together and fun to perform!
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Aims and objectives: The study aim was to explore the use of an Intensive Care Unit (ICU) diary within four different ICUs units in Sweden and thereby contribute to practice guidelines regarding the structure, content and use of an ICU diary.
Background: ICU diaries are used to aid psychological recovery among critical care patients, but differences remain in diary writing both within and across countries. Few studies have focused on the combined views and experiences of ICU patients, family members and nursing staff about the use of ICU diaries.
Methods: Three focus groups interviews were carried out with 8 former patients and their family members (n = 5) from the research settings. Individual interviews were carried out with 2 patients, a family member and a nurse respectively. Observations, field notes, documentary analysis and conversations with nursing staff were also conducted. Consolidated criteria for reporting qualitative research (COREQ) was followed.
Results: The qualitative findings firstly consisted of a matrix and descriptive text of the four ICU contexts and current practices. This highlighted that there were similarities regarding the aims and objectives of the diaries. However, differences existed across the case study sites about how the ICU diary was developed and implemented. Namely, the use of photographs and when to commence a diary. Second, a thematic analysis of the qualitative data regarding patients' and family members' use of the ICU diary, resulted in four themes: i) the diary was used to take in and fully understand the situation; ii) the diary was an opportunity to assimilate warm, personalised and human care; iii) the diary was used to manage existential issues; and iv) the diary was a tool in daily activities.
Copyright: 2024 Johansson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data cannot be shared publicly because of the risk of identifying individual study participants. Data requests may be sent to the head of research at Region Kalmar County, Professor Cecilia Fagerstrm: cecilia.f...@regionkalmar.se.
Funding: The first author was partly financed for her PhD education of which this study forms a part by the Health Research Council of South East Sweden and Kalmar County Council. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript".
There are approximately 41070 admissions to 82 adult intensive care units in Sweden annually [32]. ICUs are situated in university, county and district hospitals. County and district hospitals have general ICUs. The ICUs in university hospitals may have a range of specialized ICUs, for example; burns ICU, neurosurgical ICU, medical ICU, surgery ICU and thoracic surgical ICU. The specialized ICUs serve other hospitals in their region when specialized care is required. The study took place in 2018 between March and October at four different Swedish ICUs (units A, B, C and D) in four ICU settings, equal to four cases where the ICU diary has been developed and implemented. Henceforth, ICU settings are called cases, which means everything associated with the settings, such as documents, observations, notes, routines, interviews, and study participants. One ICU setting was a university hospital, and three were county hospitals (See Table 1).
Field notes consisted of a continuous record of responses reported from the different units according to the study protocol. They were written by MJ both in the ICU but also directly after each observation period.
Patients had been discharged for a period of seven to fourteen months depending on their recovery process and were invited to bring family members with them to the focus group session. The inclusion criteria for patients and family members included; being a former ICU patient, having an ICU diary, being willing to share their experiences and aged 18 years or older.
Second, to answer the remaining research questions (2, 3 and 4), a thematic analysis, inspired by Braun and Clark [34], was conducted of the qualitative data from the focus group interviews, individual interviews, telephone interview, and textual message [34]. This approach was deemed suitable for identifying, reporting and interpreting patterns of meaning within the transcribed data. It was also chosen for being a flexible yet rigorous method for examining the perspectives of different research participants, highlighting similarities and differences and also generating unanticipated insights [34].
Table 2 below provides an overview matrix of the main similarities and differences regarding the structure, content, and ICU diary use within participating ICU settings arising from the systematized observational study, documentary and informal field interview data as outlined above. The matrix is supplemented with a written summary description of the four ICU contexts and main current practices drawn from the qualitative data. Core findings from a thematic analysis of the qualitative data are subsequently presented.
It was self-evident by nursing staff in all ICUs to involve family members in writing/reading the diary without them feeling obliged to write. Family members might come and go around the clock at some units, but in others, staff agreed on their visiting times. ICU nursing staff had diverse experiences of diary writing from 10 to 23 years. Prepared diaries were readily available on the ICUs in a room intended for follow-up services.
Written guidelines were found in one ICU and comprised inclusion, exclusion criteria, writing style, informed consent, the process around photographing, and handover of the diaries. Another unit was developing written guidelines, but the other units had only oral guidelines about the structure, content, and use of the diary. Experienced nursing staff communicated informal guidelines to new employees and less experienced ICU nursing staff. The absence of clear, written guidelines meant that many patients did not receive a diary because of the hesitation in deciding which patients should get a diary and how to prioritise the process. The uncertainty was expressed as a cause of frustration among the participant nursing staff.
Other entries were psychosocial, which expressed and confirmed the presence of the family members at the bedside. Family members added information about what happened at home or greetings from other family members. Entries included reflections around the weather, seasons, Swedish festivals, sports events together with entries of a more personal nature. Staff members who wrote the entry included the whole team, dated, and signed the note. A unique contribution from staff at one ICU was a poem at the end of the diary intended to provide a respectful content if diary entries were sparse.
The nursing staff did not open an ICU diary for patients with severe brain injuries, and dementia, poor prognosis nor for patients who did not speak/understand Swedish. Often, some nursing staff commenced a diary immediately when a patient was admitted to ICU, but sometimes days elapsed, and the diary writing did not take place. Reason/s for the delay included lack of time or difficulties to start the diary as the summary was deemed to be the most essential and extensive aspect. In some units, assistant nurses frequently opened a diary as they had more time to initiate the process than the registered nurses.
Three ICUs used a digital camera with memory, where nursing staff might print out the photograph straightaway and then delete the original from the memory card. The fourth ICU moved and stored the pictures in image management on a desktop. At one ICU, the pictures were pasted in the diary immediately, close to the written text, so that text and image interacted. Sometimes, photos were collected in an envelope at the back of the diary.
Another ICU used mounted the photos directly in their context in the diary but left the other side empty. This made it possible for the patient to remove the picture but without destroying any existing text.
Patients and family members requested ongoing summaries in the diary, as the information was sometimes perceived to be insufficient or irregularly provided, especially during more extended periods of stay. The diary was mainly experienced as a tool to help process the time in ICU by describing what daily life looked like, which was not included in the medical records.
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