NUR 440 Module 7 Final Project: Integrative Review example

Writing the Days They Cannot Remember: An Integrative Review of ICU Diaries and Psychological Recovery After Critical Illness

[Student Name]

Southern New Hampshire University

NUR 440: Research and Evidence-Based Practice

Final Project: Integrative Review

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Writing the Days They Cannot Remember: An Integrative Review of ICU Diaries and Psychological Recovery After Critical Illness

Introduction

Many people who survive critical illness leave the intensive care unit with a gap in their memory, fragments of frightening delusional experiences and, for a substantial minority, symptoms of posttraumatic stress disorder, anxiety or depression that persist for months. Families carry their own psychological burden. One nursing intervention developed to address this is the ICU diary: a notebook in which nurses and relatives write, in plain language and often with photographs, what happened to the patient day by day, which is given to the patient after discharge to help them make sense of the time they cannot recall.

On the composite 24-bed medical-surgical intensive care unit where this review originated, a small group of nurses has started diaries informally for some long-stay patients. The unit's practice council asked whether the practice should be formalized. The PICOT question guiding this review is: in adults admitted to intensive care who require mechanical ventilation, and their relatives (P), does an ICU diary (I), compared with usual care (C), reduce symptoms of posttraumatic stress disorder, anxiety and depression (O) in the months after discharge (T)?

Methods

The review followed the five stages of the integrative review method: problem identification, literature search, data evaluation, data analysis and presentation (Whittemore & Knafl, 2005). CINAHL Complete, PubMed and the Cochrane Library were searched using combinations of intensive care, critical care, diary, diaries, posttraumatic stress, PTSD, depression, anxiety, psychological recovery, family and relatives. Reference lists of included reviews were checked for additional trials.

Studies were included if they were randomized trials or systematic reviews of ICU diaries in adult patients or their relatives, reported at least one psychological outcome and were published in English. Qualitative studies of patient experience were noted for context but not included in the outcome synthesis. Each study was appraised for design, sample size, risk of bias and follow-up, and assigned a level of evidence. From the records screened, two randomized trials and two systematic reviews met the criteria and were selected as the core evidence.

Results

Table 1 summarizes the four included studies.

Table 1

Evidence Table: ICU Diaries and Psychological Outcomes

The first multicenter randomized trial reported a striking result. Among 352 patients randomized one month after discharge, those who received their diary had a significantly lower incidence of new PTSD at three months, 5 percent compared with 13 percent in the control group (Jones et al., 2010). The later and larger trial did not confirm this. Among 657 ventilated patients randomized during their stay, only 339 completed the three-month assessment, and significant PTSD symptoms were reported by 29.9 percent of the diary group and 34.3 percent of controls, a gap too small to reach statistical significance (Garrouste-Orgeas et al., 2019).

The two reviews reflect the evolving evidence. The Cochrane review, which included only three studies, concluded that there was minimal evidence either way, noting one small study in which relatives of patients who received diaries had fewer PTSD symptoms (Ullman et al., 2015). The later meta-analysis pooled 12 studies and found that diaries were associated with a lower risk of depression and better quality of life for patients, but not with lower anxiety or PTSD, and found no benefit for relatives (Barreto et al., 2019).

Synthesis

Organizing the findings by outcome clarifies what the evidence shows. For PTSD, the evidence is conflicting and, on balance, does not support a clear benefit: one positive trial is offset by a larger negative trial and a meta-analysis that found no reduction. Several differences may explain the conflict. The first trial randomized patients a month after discharge and measured new-onset PTSD, while the second randomized during the ICU stay and measured symptom levels; the second also lost nearly half its participants before follow-up, which weakens its precision. Diary content and how the diary was introduced to patients also varied across studies.

For depression and quality of life, the pooled evidence is more encouraging. The meta-analysis suggests that diaries may help patients recover emotionally and functionally even if they do not prevent PTSD, a benefit that is plausible because diaries fill memory gaps and help patients understand the seriousness of their illness. For relatives, early small studies suggested benefit, but pooled evidence did not confirm it.

Recommendation

Based on this review, ICU diaries can reasonably be offered to adult patients who require prolonged mechanical ventilation as a low-cost, low-risk supportive intervention that may reduce depression and improve quality of life after discharge. They should not be introduced to staff or families as a proven way to prevent PTSD. If the unit formalizes the practice, it should provide brief staff training on writing entries in plain, factual and compassionate language, obtain consent for photographs, agree on who gives the diary to the patient and when, and offer a follow-up conversation to help patients read it. The unit could track uptake and ask patients at a follow-up visit whether the diary was helpful, recognizing that such local data can guide implementation but cannot prove effectiveness.

Limitations

This review has limits. Only four core studies were included, and the review relied on published summaries and abstracts for some details. The trials differed in timing, outcome measures and diary format, which limits direct comparison, and loss to follow-up was substantial in the largest trial. Most studies were conducted in Europe, where intensive care practices and follow-up services may differ from those in the United States. Newer trials may have been published since the reviews were completed.

Conclusion

ICU diaries are a humane nursing intervention that helps patients reconstruct a period they cannot remember. The evidence reviewed here does not show that diaries reliably prevent PTSD, but pooled data suggest they may reduce depression and improve quality of life. That makes diaries worth offering with clear, honest expectations and good implementation, and worth continuing to evaluate as new evidence appears.

References

Barreto, B. B., Luz, M., Rios, M. N. O., Lopes, A. A., & Gusmao-Flores, D. (2019). The impact of intensive care unit diaries on patients' and relatives' outcomes: A systematic review and meta-analysis. Critical Care, 23, Article 411. https://doi.org/10.1186/s13054-019-2678-0

Garrouste-Orgeas, M., Flahault, C., Vinatier, I., Rigaud, J.-P., Thieulot-Rolin, N., Mercier, E., Rouget, A., Grand, H., Lesieur, O., Tamion, F., Hamidfar, R., Renault, A., Parmentier-Decrucq, E., Monseau, Y., Argaud, L., Bretonnière, C., Lautrette, A., Badié, J., Boulet, E., . . . Timsit, J.-F. (2019). Effect of an ICU diary on posttraumatic stress disorder symptoms among patients receiving mechanical ventilation: A randomized clinical trial. JAMA, 322(3), 229-239. https://doi.org/10.1001/jama.2019.9058

Jones, C., Bäckman, C., Capuzzo, M., Egerod, I., Flaatten, H., Granja, C., Rylander, C., & Griffiths, R. D. (2010). Intensive care diaries reduce new onset post traumatic stress disorder following critical illness: A randomised, controlled trial. Critical Care, 14(5), Article R168. https://doi.org/10.1186/cc9260

Ullman, A. J., Aitken, L. M., Rattray, J., Kenardy, J., Le Brocque, R., MacGillivray, S., & Hull, A. M. (2015). Intensive care diaries to promote recovery for patients and families after critical illness: A Cochrane systematic review. International Journal of Nursing Studies, 52(7), 1243-1253. https://doi.org/10.1016/j.ijnurstu.2015.03.020

Whittemore, R., & Knafl, K. (2005). The integrative review: Updated methodology. Journal of Advanced Nursing, 52(5), 546-553. https://doi.org/10.1111/j.1365-2648.2005.03621.x