The theory of posttraumatic growth arose from accounts of various trauma survivors experiencing not only distress but also growth and change. An intensive care unit admission is an unplanned, sudden, and traumatic experience, and many survivors have posttraumatic stress that can lead to posttraumatic stress disorder. Survivors leave the intensive care unit with new functional impairments that drive depression, and they frequently experience anxiety. Amidst the stress of understanding the trauma of an intensive care unit admission, survivors can grow in their world views, relationships, and sense of self. Understanding posttraumatic growth in intensive care unit survivors will inform health care providers on how to help survivors understand their new difficulties after an intensive care unit stay and facilitate growth. This article is a conceptual review of posttraumatic growth, identifiers of posttraumatic growth, and how the tenets of the posttraumatic growth theory apply to intensive care unit survivors. Health care professionals, specifically nurses, can incorporate practices into their care during and after the intensive care unit stay that encourage understanding and positive accommodation of new difficulties brought on by the intensive care unit hospitalization to support survivor growth. Opportunities for research include incorporating posttraumatic growth assessments into post–intensive care unit clinics, self-help materials, and various programs or therapies. Outcomes associated with posttraumatic growth are listed to suggest directions for research questions concerning posttraumatic growth in intensive care unit survivors.
Traumatic events are life crises that disrupt the normal patterns of a person’s life and challenge a person’s beliefs and understandings of the world, known as their assumptive world.1,2 It has long been the notion that psychological, physical, and social distress follow a traumatic event as a person and informal caregivers (eg, family members, significant others, close friends) attempt to incorporate the trauma into their life.1 Negatively accommodated trauma (eg, “the world is out to get me”) can lead to distress characteristic of posttraumatic stress (PTS).2 However, there are also accounts of people experiencing positive change after a traumatic event, which has led to the concept of posttraumatic growth (PTG). The displacement of one’s understandings and beliefs that may occur after a traumatic event offers the opportunity to reexamine one’s pretrauma self, relationships, and philosophy of the world, and to grow new perspectives that incorporate the trauma into reality.3
Posttraumatic growth is defined as the positive psychological change and improvement that can result from processing the trauma.4 A new worldview that allows for trauma to be positively accommodated (eg, “bad things are a natural part of life”) can lead to engagement with social support, to deeper spiritual beliefs, and/or to development of a new sense of self characteristic of PTG. In this conceptual review, we explore the concept of PTG in a critical care population, propose a role for critical care clinicians in the facilitation of PTG by using strategies to engage patients and informal caregivers, and suggest future directions for critical care PTG research.
“This growth can be likened to the growth that occurs in a forest after a wildfire: the destruction does not render an end to the life of the forest.”
Differentiating PTS, Posttraumatic Stress Disorder, and PTG
Posttraumatic growth and PTS can coexist, and PTS can serve as a precursor to both PTG and post-traumatic stress disorder (PTSD).4 Both PTS and PTG involve cognitive processing in the form of ruminating about the trauma and upended life assumptions.5 Intensive care unit (ICU) survivors often face unwanted and excessive thoughts of the traumatic event (eg, ICU admission and stay), known as intrusive rumination; feeling out of control of one’s thoughts and situation is characteristic of PTSD.6 Survivors of the ICU eventually seek purpose and want to make sense, of or find meaning in what has happened to them in the ICU, maturing from intrusive rumination to a more controlled and deliberate process.7 This maturation and effort to find meaning and positively accommodate the experience of critical illness characterize PTG. Importantly, the theory of PTG does not suggest that trauma benefits life or is sufficient for growth but suggests that there is opportunity to understand trauma in such a way that worldviews grow and new perspectives develop.
Critical Illness and ICU Admission as Sources of Trauma
Trauma is a highly stressful event that uproots a person’s pretrauma assumptive world.1,4 Intensive care unit admissions, whether the result of an injury (eg, vehicle collision) or illness, are disruptive in their often sudden and unplanned nature, with a potentially serious risk to health. Survivors of the ICU may experience trauma from multiple sources during an ICU admission, including sources that a person deems disturbing and confusing (eg, hallucinations of abuse or altercations, delirium, awake anesthesia, catheterization, traumatic intubation, disfiguration).1,8,9 Previous trauma that violates a person’s physical body (eg, sexual abuse, assault) can prime a patient to experience the physical care in the ICU as a traumatic event (eg, physical restraints can be a trigger).10,11 The ICU admission has lasting impacts on the social, emotional, and physical domains of a person’s life after hospital discharge. These impacts can affect both internal personal characteristics and how someone operates in their external world. Intensive care unit survivors experience high rates of PTSD, depression, and anxiety.12–16 Ongoing psychological sequelae can make integrating or participating in social roles difficult.12 Impairments in activities of daily living (eg, bathing, dressing)12,17 may contribute to an inability to return to work.18 One ICU survivor described life after intensive care as follows:
I honestly didn’t realize just how many people give up after the traumatic experiences from ICU. The physical and psychological discomfort of cycling between pain and depression felt impossible to escape at times. [coauthor L.G.]
The life-shattering nature of critical illness and ICU admission creates grounds for PTG to occur. Thus, there is a need to further understand the prevalence and experience of PTG in the critical care population.
“Fire, like trauma, may activate seeds and sprouts that bring new life to trees, trees that grow with thicker bark than before as an adaptation to the trauma.”
Overview of PTG
The current literature on PTG includes many populations with specific types of trauma or adversity.1 Posttraumatic growth is well documented in the contexts of abuse,19,20 disaster,21 and combat.22,23 Survivors of cancer,24–26 HIV infection and AIDS,27 and heart disease28 also experience PTG. Moreover, some evidence indicates that PTG is present with acquired brain injury, an impairment prevalent in many ICU survivors due to physical trauma or delirium.29–31
Tedeschi and Calhoun described PTG as having 3 broad domains: personal, interpersonal, and existential.1,3 People develop a new way of seeing themselves through their hardship, both in appreciating the strengths they have developed to help them through their struggle and accepting those once-blameworthy qualities that are out of their control. Interpersonally, those experiencing PTG may place increased value on family and friends, with newfound importance of empathy and goodwill toward others. Existentially, there are changes in perception of the world, spirituality, religion, and/or philosophy of life.
The extent to which different individuals (eg, ICU survivors, caregivers) experience PTG varies.6 The Figure illustrates a proposed framework for growth after critical illness (domains informed by Tedeschi and Calhoun3 ). Traumatic experiences and posttraumatic states are highly varied, unique to the individual, and nonlinear, but some people experience positive growth in the aftermath of trauma. This growth can be likened to the growth that occurs in a forest after a wildfire32 : the destruction does not render an end to the life of the forest. Fire, like trauma, may activate seeds and sprouts that bring new life to trees, trees that grow with thicker bark than before as an adaptation to the trauma. This is a protective evolution of the life of the tree, its roots, and the forest in which it lives. Similarly, people, having experienced trauma, may find that seeds of hope and development in their philosophy of life, self, and relationships with others ultimately increase strength to withstand future trauma.
The PTG Inventory is a validated measure for quantifying PTG outcomes by assessing 5 factors associated with the domains of PTG4 : (1) greater appreciation of life, and a changed sense of priorities; (2) warmer, more intimate relationships; (3) greater sense of personal strength; (4) recognition of new possibilities or paths in life; and (5) spiritual development.
Because each person who experiences a trauma (eg, critical illness and ICU admission) is unique and brings their own set of pretrauma assumptions and understanding of the world, domains of growth and how much growth occurs will vary across individuals.33 For each factor of the PTG Inventory, more specific growth outcomes are measured to understand the individual nuances for each person (eg, compassion toward others, wisdom in understanding the world).34
Little is known about PTG in survivors of critical illness. However, existing literature in other populations suggests that there is greater potential for PTG if a patient continually revisits and processes the trauma and attempts to accommodate it into their worldview.4 Cognitively revisiting and processing a traumatic event (eg, ICU admission) is known as deliberate rumination.4 Critical care teams may be able to foster PTG by encouraging the process of deliberate rumination and appraisal of critical illness. Because starting points, end points, and trajectories of PTG are different for each individual,25,33 a patient’s PTG journey, with unique and varying characteristics, may be positively influenced by the critical care team. This idea is supported by the reflection of an ICU survivor:
The resiliency that can result from trauma cannot come without acknowledgement of loss. There is no single correct way to address trauma in each individual struggling to rise from the ashes. Different things will resonate with different people. [coauthor L.G.]
Thus, knowing characteristics of patients that signal a propensity for PTG can alert providers to those who will most likely benefit from facilitation efforts.
Factors Contributing to PTG
Posttraumatic stress disorder has been shown to be the most significant factor predicting PTG; thus, patients exhibiting signs and symptoms of PTS may be candidates for intervention targeting PTG.35 The presence of social support strongly predicts PTG.24,35–37 Younger people report higher levels of PTG; it has been hypothesized that younger individuals find trauma more disruptive to their assumed pretrauma world beliefs and thus have greater potential for PTG.19,38,39 Similarly, higher PTG is reported by individuals who perceive an illness as more intrusive and intense.24 Finally, spirituality, faith, and religion are factors associated with PTG across different populations, with openness to religious change as a specific marker of growth.40–43 These observations may guide providers in prevention of distress and treatment of ICU survivors and encourage researchers to investigate if these findings persist in ICU populations.
Implications for Practice
Post-ICU physical, emotional, and cognitive impairments require specific medical care. Intensive care unit clinicians can leverage inpatient and ICU recovery care models to provide relevant services that increase the likelihood of PTG after hospital discharge.
Incorporating PTG Into the Inpatient Setting
Tedeschi and Calhoun laid the groundwork for incorporating PTG into clinical practice. These strategies can be applied to integrating PTG into ICU treatment by critical care providers. The expert companion model suggests that a person aiming to facilitate PTG must approach the traumatized person with humility and remain open-minded to that person’s unique journey as opposed to treating them like “symptoms just to be altered.”44 Trauma-in-formed care in the ICU is recommended for critical care providers to understand how patients handle difficult situations and involves inquiring about what the patient was like before the ICU or if the patient has experienced previous trauma.11 This information can inform the interprofessional ICU team so they can address and aid deliberate cognitive processing of ICU-related trauma and help the patient mature past initial confusion and intrusive thoughts related to their critical illness. Likewise, summarizing the course of illness, outlining logistics of recovery, and suggesting potential therapies for informal caregivers are vital to helping the patient cognitively process a traumatic event.44 The critical care team must actively listen to patients willing and able to discuss the nature of their condition and hospitalization, identify growth-related comments, and use those comments as examples while explaining PTG. Once the critical care team develops an established language for PTG, they can act as coaches for patients and informal caregivers and thus facilitate PTG.45
Nurse-Led Inpatient Initiatives
As critical care professionals with the most patient-contact hours in the hospital, nurses are crucial in facilitating PTG. We suggest that nurse facilitation of ICU diaries, interacting and incorporating families into care, and motivational interviewing can encourage PTG. Nurses can also engage other interdisciplinary team members to participate in the following efforts to facilitate PTG.
Intensive Care Unit Diaries
Intensive care unit diaries containing details about hospitalization and daily progress can frame cognitive processing of a patient’s trauma.46 Such diaries are written for the patient by the critical care team or family and are associated with decreased anxiety, depression, and PTSD symptoms after critical illness.41,47 Intensive care unit diaries can also serve as a source for deliberate rumination (ie, conscious thoughts to understand the harmful event and its impact), helping the patient understand what has happened and how it fits into their current life.4,6 This enhanced understanding of the hospital course can facilitate positive incorporation of the patient’s trauma and contribute to PTG. The cost of ICU diary implementation is minimal compared with the potential benefit of improved quality of life for the patient.46
Family Engagement and Addressing Caregiver Burden
Nurse-led predischarge coaching of family members creates a home environment more conducive to PTG. Support from psychologically healthy family and friends who have an understanding of the ICU experience can create a home environment where PTG can fully develop. Family members and loved ones, unlike an unconscious patient, are completely alert to all aspects of an active hospitalization. This experience can often be frightening and stressful, and it can have lasting effects on well-being (eg, depression, anxiety, PTSD).16,48–51 Family members experience trauma alongside the patient in the hospital and are often required to quickly transition to caregiver upon hospital discharge. The critical care inter-professional team must note the probability and severity of caregiver distress and intervene when possible to optimize family members’ transition to the caregiver role. Direct and frequent interaction with family members by nurses, as well as their dedication to patient advocacy, position them to identify stressors and influence the overall well-being of the family unit.
Questionnaires to evaluate caregiver anxiety, depression, stress, and family-specific needs are widely available.52 Although not specific to critical illness, the findings from these questionnaires can be used by nurses to activate social work services for appropriate referrals and facilitate the caregiver’s transition while still in the resource-rich setting of the hospital. Early recognition of family members’ psychological symptoms (eg, depression, anxiety, uncertainty) can lead to improved caregiver support and, thus, enhanced patient PTG after discharge.
Motivational interviewing assesses a patient’s goals and willingness to change prehospital assumptions to improve the chance of incorporating positive behavior change after discharge, thus facilitating PTG. Motivational interviewing theory dictates that patients are the ultimate influencers in their own healing.53 The key tenets of motivational interviewing are assessing awareness and readiness to grow, accepting and accommodating a patient’s ambivalence toward change, and maintaining composure during potential ambivalence.54 One patient described his nurse-led motivational experience as follows:
Nurses may need to dial into what drives or motivates patients. Sometimes it can be much easier to have conversations about PTG with someone the patient can identify with or who has similar values. When I was in the step-down unit, one of the nurses brought along another nurse who was a runner and understood how big a loss it would be for me if I couldn’t run again. This example shows the importance of “matching” so patients can work with others who validate their loss instead of skipping ahead to attempts to engender positive growth. Patients may also need to develop new goal-setting skills, even if they are already in the habit of goal setting. [coauthor L.G.]
Rather than direct patients toward goals determined by clinicians, motivational interviewing techniques promote active listening to guide problem identification and to prompt the patient’s motivation toward new goals and growth.54 The aim for motivational interviewing of contemplating and producing behavior change directly addresses a changed sense of priorities after trauma.4 Motivational interviewing has been used successfully to increase physical activity in cardiac patients, treatment adherence in psychiatric patients with dual substance abuse disorders, engagement in alcoholism treatment, and weight loss in patients with diabetes.54–57 Motivational interviewing is a cost-effective and relevant intervention for nurses to use when communicating with patients in the ICU and can encourage change and contribute to a patient’s sense of control in their healing strategy, thereby increasing the chance of PTG.
Incorporating PTG into ICU Recovery Services
The effects of an ICU admission extend beyond discharge. Therefore, it is vital that patient care continues after ICU discharge to ensure a safer transition back to normal life and aid the facilitation of PTG. Intensive care unit clinicians building relationships with and referring patients to post-ICU recovery clinics can help transition a patient in an environment uniquely structured to cultivate PTG further.
Post-ICU clinics, where available, can be a comprehensive resource for patients living in the aftermath of critical illness. The clinic is uniquely able to administer neuropsychological tests, monitor mental and physical health status, and connect patients with resources.58,59 Post-ICU clinics also help patients understand the physical and cognitive impairments that often occur after ICU discharge; they can enable recovery and thus can facilitate PTG.60 Although there is no universally accepted structure for post-ICU clinics, integration of critical care staff may help an ICU survivor make sense of their time in the ICU and engage in productive and deliberate rumination about their symptoms persisting after the ICU. The services (eg, case management, pharmacy, medicine, psychology, physical therapy, occupational therapy, palliative care) provided by many post-ICU clinics may directly support and assist ICU survivors in accessing the 5 factors of PTG (Table 1).61
Proposed Research Priorities for PTG After Critical Illness
Survivors of ICU care can experience uniquely high levels of trauma and, we theorize, have the opportunity to build PTG. On the basis of what we know from other populations and the limited information and research we have on ICU populations, additional research on post-ICU PTG has the potential to markedly improve care for ICU survivors. Table 2 details suggested priorities and areas for research. Pressing needs include understanding what PTG domains (ie, changes in self, relationships, and philosophy of the world) and trajectories are unique to ICU survivors living with chronic illness, which interventions can facilitate PTG in ICU survivors, and how to disseminate and implement new knowledge to critical care providers on the frontlines to better encourage PTG in their patients. The role of the caregiver in fostering PTG also deserves more study. Informal caregivers endure their own distress from the critical illness, as well as from post-ICU changes in their loved one’s personality and functional status.62,63 The role of the informal caregiver and family in facilitation of PTG during and after the ICU stay is unknown, and empirical investigation could elucidate the impact of the caregiver on PTG.
In this conceptual review, we describe an ICU stay as a traumatic experience that leaves patients with new impairments in cognitive, mental health, and physical functioning. In the wake of ICU-related trauma, amidst the uncertainty of recovery, opportunity emerges for personal growth, like fire-induced sprouting of seeds enables new life after a natural disaster. Because of the intensity and breadth of trauma that patients in the ICU experience, they are uniquely positioned to build PTG. Similarly, critical care nurses, physicians, and other medical staff are uniquely positioned and equipped to partner with patients and caregivers to cultivate PTG. Critical care providers and researchers have the opportunity to support ICU survivors as they engage with their trauma and to facilitate PTG from PTS during the transition to life after the ICU, ultimately, helping ICU survivors engage with life in new ways. Additional research is needed to better understand and foster PTG in critical care populations.
Dr Boehm is receiving grant funding from NHLBI (K12HL137943-01) and the American Association of Critical-Care Nurses. The authors’ funding sources did not participate in the planning, collection, analysis or interpretation of data or in the decision to submit for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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