Facilitating Posttraumatic Growth After Critical Illness

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.

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:

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.

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 new-found 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:

Thus, knowing characteristics of patients that signal a propensity for PTG can alert providers to those who will most likely benefit from facilitation efforts.

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.

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.

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-informed 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 

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 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 

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:

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.

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 

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.