Background

After critical illness, patients are often left with impairments in physical, social, emotional, and cognitive functioning. Peer support interventions have been implemented internationally to ameliorate these issues.

Objective

To explore what patients believed to be the key mechanisms of effectiveness of peer support programs implemented during critical care recovery.

Methods

In a secondary analysis of an international qualitative data set, 66 telephone interviews with patients were undertaken across 14 sites in Australia, the United Kingdom, and the United States to understand the effect of peer support during recovery from critical illness. Prevalent themes were documented with framework analysis.

Results

Most patients who had been involved in peer support programs reported benefit. Patients described 3 primary mechanisms: (1) sharing experiences, (2) care debriefing, and (3) altruism.

Conclusion

Peer support is a relatively simple intervention that could be implemented to support patients during recovery from critical illness. However, more research is required into how these programs can be implemented in a safe and sustainable way in clinical practice.

The use of peer support as a method of supporting survivors of critical illness is gaining momentum internationally.14  After critical illness, many patients and their loved ones are left with lingering physical, emotional, cognitive, and social problems.57  Peer support–based interventions have emerged as a strategy to ameliorate these issues despite a lack of evidence proving the interventions’ efficacy.18  These programs need to be evaluated to understand their mechanisms of effectiveness with the goal of measuring clinical impact.

We undertook a secondary analysis of an existing data set to explore what patients believe to be the key mechanisms of effectiveness of peer support interventions during intensive care unit (ICU) recovery. Previous analysis has explored the key mechanisms of ICU recovery services9 ; this analysis is distinct in that it critically examined how peer support provided benefit within these services and sought to elucidate the effective mechanisms from the perspective of patients.8 

Methods

The Western Health Research Ethics Committee (Australia), Vanderbilt University Institutional Review Board (US), and the South West (Cornwall and Plymouth) Research Ethics Committee (UK) approved this study.

Participants were recruited from ICU recovery services through the Society of Critical Care Medicine’s THRIVE program. Clinicians approached their patients about the study and passed contact details of patients who were interested in participating to the research team. We obtained the patients’ consent before undertaking interviews.

THRIVE was established to bring together critical care clinicians who use ICU follow-up clinics and peer support models to improve patient and family outcomes. Within the THRIVE Collaboratives, 6 models of peer support are used, and all 6 are represented within this study.1  All programs involved in the THRIVE ICU follow-up clinic collaborative use a multidisciplinary approach.

We used purposive sampling strategies in this study. We interviewed patients from THRIVE sites across the United States, United Kingdom, and Australia. We also interviewed patients who received no recovery service (intervention) to contextualize the perceived benefits of and to understand any negative consequences of peer support. We recruited patients who were not part of a THRIVE program through the Society of Critical Care Medicine’s social media. We interviewed the participants’ caregivers and family members separately. We conducted interviews via telephone, and each patient was interviewed once. We used a semistructured interview format (Supplement—available online only, at www.ajcconline.org), and all interviews were audio recorded and transcribed verbatim.

Interviews were conducted by 3 female researchers (J.M., L.M.B., E.H.) and 1 male researcher (J.J.). All are clinicians trained in qualitative research and critical care clinical practice (nursing, physiotherapy, and psychology). All of the researchers described their professional background and their role in the research. The interviewers were not part of the clinical care team that had cared for the participants they interviewed. Participants were given the opportunity to ask any questions about the study before it began. Interviews lasted 20 to 60 minutes.

We used framework analysis as a systematic and transparent method of analyzing themes and produced matrices to compare the occurrence of themes.10  Two members of the research team (J.M., L.M.B.) coded data and 3 (J.M., L.M.B., T.J.I.) analyzed the data. We initially grouped the data under broad repeated themes, and then we used the framework method to synthesize the data for specific mechanisms related to peer support effectiveness to generate themes. An audit trail was uploaded onto a secure site for researchers involved in the analysis. Member checking was undertaken, and members of the research team not directly involved in data analysis or collection conducted a peer review of the final analysis (C.M.S., K.J.H.).

Results

We conducted interviews with 52 patients from 14 THRIVE sites across the United States, United Kingdom, and Australia and 14 former ICU patients who received no recovery service (total interviews = 66). Interviews took place between July 2018 and February 2019. Interviews were stopped in February 2019 because there was a consensus among the research team that no new themes were emerging from the data.

The median (interquartile range) age of the participants was 52 (40-62.5) years and 40 (60%) were female. All patients approached consented to being interviewed.

Patients described 3 primary mechanisms by which peer support provided benefit: (1) sharing experiences, (2) care debriefing, and (3) altruism (see Figure). Illustrative quotes and how these mechanisms manifested are shown in the Table. We found no distinct differences between those who did and did not take part in peer support programs.

Sharing Experiences

Sharing experiences supported recovery in several ways. Patients’ anxiety decreased because they felt reassured that other patients had similar issues. Participants described increased hope and motivation with a subsequent reduction in social isolation. Interacting with patients who were further along the recovery trajectory helped patients visualize and understand that their condition could improve (internal validation).

Care Debriefing

Understanding the recovery trajectory and inter-acting with others allowed patients to better comprehend their ICU illness narrative and supported them in navigating complex health care systems. Care debriefing also supported realistic goal setting and helped patients calibrate accurate expectations of recovery and the recovery time frame (external validation). Interacting with others on the same pathway helped patients understand their health challenges and visualize their progress (expectation management).

Altruism

The sense of giving back to other patients, the hospital system, and the ICU was an important benefit of peer support. Patients believed that their participation in peer support was advantageous to a variety of stakeholders including other patients, care-givers, and ICU staff. Taking part in peer support programs gave patients a sense of purpose.

Discussion

This brief report illustrates the perceived benefit of peer support from the perspective of an international cohort of critical care patients. The use of peer support has been established in other populations; this research adds to the growing body of evidence about its mechanisms of effectiveness with critical care survivors.2  Providing a sense of purpose was an important component of peer support effectiveness, distinct from that provided by post-ICU clinics.8  Sense of purpose is a modifiable risk factor associated with all-cause mortality.11  Peer support could therefore be a low-cost solution that provides important psycho-social benefits after critical illness. Peer support also appears to reduce social isolation in patients. Social isolation and loneliness have been shown to increase mortality across a wide range of disease pathways.12  Peer support may mediate this isolation; however, more work is required to understand this relationship.

Our study has limitations. We interviewed patients recovering from critical illness who were actively engaged in programs of support; therefore, this study may not represent the views of patients who are not involved in these support structures. Furthermore, although we used contemporary qualitative methods with several processes to enhance rigor, other interpretations of these data are possible.

In conclusion, peer support appeared to improve outcomes through 3 main mechanisms: sharing experiences, care debriefing, and altruism. Future work should examine outcome measures that align with these mechanisms of effectiveness to help us understand the clinical impact of peer support programs in the post-ICU period.

ACKNOWLEDGMENTS

We would like to acknowledge the wider THRIVE steering group within the Society of Critical Care Medicine.

This work does not necessarily represent the views of the US government or the Department of Veterans Affairs.

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Footnotes

FINANCIAL DISCLOSURES

Drs McPeake, Sevin, and Haines’ institutions received funding from the Society of Critical Care Medicine. Dr McPeake’s institution also received funding from the THIS Institute (University of Cambridge, PD-2019-02-16). Dr Hope received funding from the National Heart, Lung, and Blood Institute of the National Institutes of Health (ICOI HL 1402-79).

 

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