Original articleExperiences of inner strength in critically ill patients – A hermeneutical approach
Introduction
Critically ill patients have described an inner strength which have helped them to endure severe illness and thus intensive care treatment (Bergbom and Askwall, 2000, Wåhlin et al., 2009), but also lack of strength, resulting in a feeling of being unable to continue to cope with their situation and thus a lack of will to strive for survival (Bergbom Engberg and Haljamäe, 1989, Gaudinski, 1977, Gardner et al., 2005, Löf et al., 2008). Patients’ tendency to give up or withdraw from difficult and painful physical conditions has been described. According to Bergbom Engberg (1991) nurses use different strategies for interrupting patients’ withdrawal. One strategy described is to encourage patients to call upon relatives for help in gathering strength and striving for survival. By alleviating patients’ feelings of fear and worries and by giving them adequate information, patients may gain energy and strength. This may then help them to concentrate on recovery (Hofhuis et al., 2008). Thinking of home and being at home can also improve patients well-being (Lindahl et al., 2003) as well as longing for coming home or the “normal” life (Karlsson and Forsberg, 2008).
Giving up or withdrawal has been seen as a part of a crisis reaction or as a reactive apathetic depression manifested five or six days after admission to the intensive care unit (Löf et al., 2008). Anxiety and fear are also common experiences. More than 70 per cent of critically ill patients felt depressed in Desbiens et al. (1996) and Hewitt's (2002) studies. The tendency to give up has also been described amongst patients in other health care settings and the term Giving Up Syndrome or withdrawal was, for the first time, described in 1968 by Engel. Giving up has been considered as one side of the intensive care delirium, that is, the hypoactive (Gaudinski, 1977, Granberg-Axell et al., 2001).
Additionally, reactions such as fear, agony, disturbed sleep and nightmares are reported (Granberg-Axèll, 2001), all of which may affect patients’ strength and will to cope. In light of the risk of depression or loss of will to go on living, it is important to raise some questions about the inner strength. What is it that makes patients struggle for survival and what promotes inner strength? Knowledge about these factors can result in caring actions that support patients in coping and striving for survival and continued life. This study focuses on phenomena that support and promote inner strength amongst patients cared for in ICUs.
Inner strength is a concept closely related to zest for life and resilience, which may be of importance for recovery, well-being, health, quality of life and happiness. We have not found any studies concerning inner strength described by patients in an intensive care context. Therefore studies from other contexts are described. These descriptions will be discussed in relation to our findings as there might be similarities independent of context. Lundman et al. (2009) in a theoretical analysis used several salutogenic concepts such as sense of coherence, hardiness, resilience, purpose in life and self-transcendence as factors associated with inner strength. They found that there are four interacting dimensions of inner strength: connectedness, firmness, flexibility and creativity. Others have described the phenomenon as a part of psychological health, a factor which influences life quality and having spiritual/existential dimensions (Bach and McDaniel, 1993, Barker, 1989, Rose, 1990). Roux et al. (2002, p86) define inner strength as “a central human resource that promotes well-being and healing”, whilst Dingley et al. (2000) found in their concept analysis six characteristics; a process of growth and transition, a point of confronting a life experience or event, deepening of self-knowledge, realisation a cognition of one's needs and sources to meet those needs, connectedness with others and focused and balanced interaction with the environment. In Moloney's study (1995), in which 12 elderly women were interviewed about the meaning of being strong which meant to survive, find power, collect memories and see patterns. To survive meant to live with losses and to cope with setbacks, to be different and put aside difficult experiences. Finding power or strength meant to have a close relationship with others and to feel being at home and have positive feelings about oneself. Patients cared for in ICUs have reported that these close relationships are vital for their struggle to survive (Bergbom and Askwall, 2000). Finally Moloney (1995) found that to collect memories and to see patterns meant to be able to tell one's own story, to regret and to live in the present, to know one's own strength and power and to be able to see the past.
Rose (1990) interviewed nine healthy women between the ages of 23 and 53 about their perceptions of inner strength. Eight themes were described: quintessence which means to know yourself and your own needs, centering meaning to have balance between external events and your own inner world, peace which meant to be able to find strength in resting and when reflecting and apprehend complexities meaning to be able to see coherence in difficult situations. Additionally Rose (1990) identified being introverted in the meaning of being aware of oneself as a subject and display humour since this releases energy and creates distance. Mutual connections with others and developing capacity from reserves of energy as well as accepting and acknowledging shortcomings and the fact that one is human were other perceptions. In relation to these findings, centering, peace, displaying humour and acknowledging shortcomings as sources for inner strength are maybe not available in a situation when being critically ill and in a serious medical condition.
Roux et al. (2000) investigated inner strength amongst women diagnosed with breast cancer. They found that relationship to family and friends was important. These results are in accordance with another study by Dingley et al. (2001) of women with heart disease. They found that the probability of developing inner strength was greater if the women experienced positive social support. This was confirmed in research by Koob et al. (2002) and Haile et al. (2002), where women with multiple sclerosis and HIV were included. Haile et al. (2002) however claimed that inner strength can be stable for some, whilst for others it seems to be more fragile and not fully developed.
All these reported studies are conducted in American or Canadian settings, and age, gender and cultural differences may exist. In order to investigate cultural differences and variations, Dingley and Roux (2003) studied inner strength amongst Latin-American women with different chronic diseases and health conditions. They found that inner strength was associated with five related dimensions: drawing strength from the past, focusing on possibilities, being supported by others, knowing one's purpose and nurturing the spirit.
Coward (1994) reported that women's inner strength was linked with having meaning in their lives, whereas for men it was important to seek challenges. There were similarities however; both women and men felt that it was important to maintain hope in order to have inner strength. Inner strength amongst men with AIDS was reinforced if they felt emotional support from others (Dancy, 1994).
Nygren et al. (2007) found in a phenomenological hermeneutical study that inner strength amongst old people between 85 and 90 years of age could be understood through the phrase “Living goes on-Living it all”. This understanding was based on the themes: Feeling competent in oneself yet having faith in others; looking on the bright side of life without hiding from the dark; feeling relieved whilst also remaining active and being the same, yet growing into a new garment.
It can be concluded that previous research has mainly focused on studies involving healthy females or women with different chronic and long-lasting diseases; or the oldest of the elderly, non-critically ill/injured patients, especially men. One must take into account that there may be individual differences in perceptions of inner strength and thus in the meaning and understanding of the phenomenon. In situations when life is perceived as threatened, life force and resilience might be seen as important parts of inner strength.
Life-force, a concept close to inner strength, is summarised by Johansson and Liljeros (1999) by three characteristics: Power as a physical manifestation from which energy is extracted, Power as an inner capability or spiritual dimension and Power as a manifestation in action, when something is performed, connected to power, effect and vigour. A person's life-force can be nourished by caring and through the relationship between the patient and the nurse (Marck, 1990). Lundman et al. (2009) conclude that inner strength means to be connected with family, friends, nature and the society and it also includes a spiritual dimension. Additionally it means to believe in one's own possibilities and to make one's own meaningful choices as well as to endure and cope with difficulties.
We have found no studies of inner strength amongst ICU patients in European countries. However, Wåhlin et al., 2006, Wåhlin et al., 2009 have studied empowerment and some of the categories that were found concerned inner strength amongst patients in the ICU.
Inner strength is an important resource affected by both inner and external factors. The phenomenon contains several aspects which seem to be interrelated. The development of inner strength may be seen as a process based on both good and challenging experiences in life. The previous studies described, have mainly focused on the phenomenon inner strength its characteristics or dimensions and not on promoting inner strength when cared for in ICU.
The ambition by this study is to contribute to the existing knowledge of “inner strength” with focus on factors that might promote such strength when critically ill and receiving intensive care. Knowledge about this could be of vital importance in the care of these vulnerable patients who in many cases live on the edge between life and death.
The aim of this study was to investigate, describe and understand what promotes inner strength in critically ill/injured patients who have received intensive care including ventilator treatment.
Section snippets
Method
A qualitative, descriptive and explorative design has been used. A hermeneutic approach inspired by the philosophy of Gadamer (1989) has influenced the aim of the study, data collection method and analysis of interview texts. A hermeneutic approach was chosen as we wanted to describe and understand what patients experienced that promoted feelings of “inner strength”. The interviews were conducted using Kvale's descriptions of interview procedures and the concept of qualitative interviews. Kvale
Findings
The findings are presented as four main themes that describe the promotion of inner strength. These are: To have the support of next of kin, The wish to go on living, To be seen and Signs of progress. In the following text, next of kin means a person who is socially and emotionally close to the patient.
Discussion
The main themes that describe the promotion of inner strength were to have the support of next of kin, the wish to go on living, to be seen and signs of progress. These findings are somewhat different from the findings of Nygren et al. (2007), but there are also similarities. For example “faith in others” could be compared to the theme “to have the support of next of kin” and “go on living” is similar to “the wish to go on living” in this study.
The presence of the next of kin, where the
Acknowledgements
We thank all former patients who have participated in the study and shared their thoughts and experiences. We are grateful to Lovisenberg Diaconal Hospital for contributing funding for the study.
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