A Qualitative Multicenter Study of Participant Experiences With an App-Based Mindfulness Intervention (Lift 2) for Critical Illness Survivors

Abstract

IMPORTANCE:

Persistent physical and mental health symptoms are common among ICU survivors and pose barriers to recovery. A randomized clinical trial of an app-based mindfulness intervention (Lift) for ICU survivors suggested improvement in mental health symptoms; however, participants’ perceptions of the intervention and its influence on their recovery is unknown.

OBJECTIVES:

We sought to understand ICU survivors’ perspectives on how the app-based mindfulness intervention influenced their recovery and identify potential mechanisms by which it influenced their physical/mental health symptoms.

DESIGN, SETTING, AND PARTICIPANTS:

This is a preplanned qualitative study of participants in the Lift 2 clinical trial at three academic medical centers between 2019 and 2023. We performed semi-structured interviews (from March 2024 to June 2024) of adults who survived an ICU stay for acute cardiorespiratory failure and completed the 1-month mindfulness program (n = 85), purposively sampling the twice-daily meditation group.

ANALYSIS:

We used a combined deductive/inductive approach to identify factors influencing the perceived effectiveness of the mindfulness intervention and general facilitators of recovery.

RESULTS:

Nineteen participants were enrolled, including six women (32%). Median age was 60 years (interquartile range, 43–66 yr). We identified themes related to participants’ perceptions of the intervention and its influence on their recovery, leveraging the Who-What-When-Where-Why-How framework to organize results. Themes included: a) participants’ receptiveness to mindfulness influenced their perceptions of its benefit (“who”); b) breathing exercises and mindfulness videos were considered the most useful content (“what”) given their positive impact on mind/body connection; c) participants described perceived reductions in dyspnea and hypertension (“why”) after using the app; d) the app-based intervention was feasible and easy to use (“how”); and e) integration of mindfulness with other rehabilitation techniques was synergistic and facilitated recovery (“where/when”).

CONCLUSIONS:

This qualitative study identifies potential mechanisms by which an app-based mindfulness intervention improved mental health and reduced physical symptom burden as perceived by ICU survivors. It also informs the development and implementation of future interventions to improve recovery from critical illness.

KEY POINTS

Question: How did an app-based mindfulness intervention for ICU survivors improve psychological distress?

Findings: In a qualitative study of 19 ICU survivors who completed the app-based mindfulness intervention, participants perceived that breathing exercises and mindfulness videos had a positive impact on the mind/body connection and that delivery via app-based format was accessible and convenient. Those who incorporated lessons from the intervention into a multifaceted approach to critical illness recovery noticed benefit.

Meaning: App-based delivery of a mindfulness intervention for critical illness survivors may help de-escalate persistent psychological and physical symptoms especially when integrated into other strategies for recovery.

Although ICU survival rates in the United States have improved over time, depression, anxiety, and posttraumatic stress disorder remain prevalent in ICU survivors and pose substantial barriers to recovery. Several interventions to address mental health of ICU survivors have been tested, including post-ICU follow up clinics, ICU diaries, and rehabilitation programs, but results are mixed and limited by methodological heterogeneity (1–3).

Mindfulness interventions have improved mental health symptoms among patients with cancer, stroke, and burn injuries (4–8). Recently, a telephone-delivered mindfulness-based training program (termed Lift) was piloted for use among ICU survivors and showed promising improvement in distress symptoms (9). A subsequent pilot randomized clinical trial (Lift 1) demonstrated that a self-guided mobile app-based version had a similar impact to a therapist-lead program (10). Following Lift 1, a multicenter multiphase optimization trial (Lift 2) was conducted to determine which intervention components were most effective (11). However, little is known about how participants perceived the intervention and integrated it into their recovery.

To address this knowledge gap, we conducted a preplanned qualitative study of participants in the Lift 2 trial to: a) understand ICU survivors’ perspectives on how the app and mindfulness intervention more broadly influenced their recovery and b) identify mechanisms by which the mobile app-based mindfulness intervention improved psychological distress as perceived by participants, organizing results using the Who-What-When-Where-Why-How framework. By pairing qualitative work with the parent clinical trial, we aimed to provide context for the findings of the Lift 2 trial and inform both the development and implementation of future interventions to improve the mental health outcomes of ICU survivors (11).

METHODS

Study Setting, Design, and Participants

This qualitative study was based on a subsample of participants who enrolled in the Lift 2 clinical trial that evaluated the optimal method for delivering a mobile app-based mindfulness program (Fig. 1) for ICU survivors with elevated post-discharge symptoms of depression (11). In this original trial conducted between August 2019 and March 2023 across three academic medical centers, participants were randomized to one of eight groups consisting of different combinations of the intervention delivery (i.e., introduction via mobile app vs. therapist call; mindfulness meditation dose once or twice daily; and management of increasing symptoms via app vs. therapist call).

Figure 1.

LIFT app overview and functions.

In the current qualitative study, which was planned a priori during the parent trial design, participants were considered eligible if they were: a) 18 years old or older; b) proficient in English; c) enrolled in Lift 2 through the study’s completion; and d) did not have cognitive impairment or severe mental illness. A total of 85 participants from the original clinical trial met these criteria. We sought to recruit roughly the same number of participants from each study site and type of ICU (medical vs. surgical), as well as a similar number of participants from each intervention arm of the original clinical trial, with broad representation across gender, age, race, education, and baseline mental health as measured by the Patient Health Questionnaire-9 (PHQ-9). Additionally, we prioritized recruitment of participants who were assigned to the twice-daily meditation (i.e., high dose) intervention arm in the original Lift 2 clinical trial, given the focus of the current study was to understand user experiences with the intervention.

During recruitment for the current qualitative study, investigators recognized that the original parent Lift 2 trial had a disproportionate number of White patients; therefore, in the current study, we intentionally prioritized recruitment of all non-White participants who met the eligibility criteria. Of 85 patients approached, a total of 48 did not respond, 17 declined, one was deceased, and 19 agreed to participate. Reasons for declining included limited recollection of the app, apathetic response to the app, inadequate time for the interview, or lack of interest. Each participant was compensated with a $20 gift card.

Data Collection

The semi-structured interview guide was developed by an intensivist and researcher with qualitative experience (K.C.V.) and a qualitative methodologist (S.G.). The multidisciplinary team (including K.C.V., S.G.) and trained study staff (M.M., L.J., E.W., C.M.) iteratively revised the interview guide during three pilot interviews to include more probes on how/whether the mindfulness intervention influenced their recovery (Online Supplement, https://links.lww.com/CCX/B649). The pilot interviews were used to generate a preliminary codebook but were otherwise not included in analyses. Study staff (all identified as women) were trained through formal coursework and close mentorship with qualitative methods experts.

Participants were verbally consented for the semi-structured interviews, which were conducted between March 2024 and June 2024 by C.M., E.W., and M.M. via audio-recording over the phone and transcribed verbatim via Webex transcription services. M.M., L.J., E.W., and C.M. reviewed the transcribed interviews for transcription errors and removed all participant identifiers. Interviewers had no familiarity with participants and gave no personal identifying information other than their name and role in the study. Interview duration was less than 1 hour.

Data Analysis

After reading three transcripts, K.C.V. created summaries of the interviews and used these to refine the preliminary codebook using a deductive approach combined with emergent findings. The deductive approach used the domains of the interview guide (based on the original aim of the preplanned qualitative study) as a starting point for the analysis; there was no other framework. Three members of the multidisciplinary research team (T.G.W., L.J., M.M.) provided validity through triangulation. Next, T.G.W., L.J., and M.M. each coded these three transcripts independently, then met to review data, perform comparative analyses of each set of codes to note similarities and differences, add new codes or collapse them as appropriate, resolve differences, and reach consensus on the codebook. Once the codebook was finalized, the remaining transcripts (n = 16) were coded by the same three investigators (T.G.W., L.J., M.M.) using a combined deductive and inductive approach to directed content analysis. Throughout this process, the study team identified factors influencing intervention effectiveness and general facilitators of recovery as perceived by ICU survivors; emerging themes of how mindfulness contributed to recovery from critical illness were also identified. Using an audit trail, the team met every 2 weeks to rereview transcripts and ensure agreement and that analyses remained grounded in data. Overall thematic saturation was assessed by study team members (K.C.V., L.J., T.G.W., M.M.), with saturation reached after 16 transcripts. Subsequent transcripts were reviewed, but no additional novel themes were identified. We used ATLAS.ti (v9.20.0, Berlin, Germany) for all qualitative analyses.

We used descriptive statistics as appropriate to characterize participant demographics and outcomes. Baseline mental health was assessed at the time they arrived home from the hospital by PHQ-9 depression scale (range, 0–27) and 7-item Generalized Anxiety Disorder scale (GAD-7; range, 0–21). Both the parent trial (“Optimizing a Mobile Mindfulness Intervention for ICU Survivors [LIFT2],” NCT04038567) and the current study were approved by the central Duke University institutional review board (Pro00100252, approved August 04, 2022, “Mobile Mindfulness After Critical Illness [LIFT2 Study]”) and all participants provided informed consent in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975. The Consolidated Criteria for Reporting Qualitative Research guideline was followed (Online Supplement, https://links.lww.com/CCX/B649) (12).

RESULTS

Participants

We conducted 19 semi-structured interviews. The median (interquartile range) participant age was 60 years old (43–66 yr old; range, 24–76 yr); six participants (32%) were women; two (11%) identified as Black/African American; and one identified as native Hawaiian (5%). Median length of ICU stay was 4 days (range, 1–22 d; Table 1). During the initial intake survey, nine participants (47%) reported at least moderate depression by PHQ-9 (score ≥ 10), and 10 (53%) reported at least mild anxiety by GAD-7 (score ≥ 5).

TABLE 1.

Participant Characteristics

Participant Characteristics	Participants (n = 19)
Age, median (IQR), yr	60 (43–66)
Gender, n (%)
Women	6 (32)
Race, n (%)
Non-White	3 (16)
White	16 (84)
ICU length of stay, d
Median (IQR)	4 (3–8)
Range	1–22
Mental health symptoms at initial assessment
Patient Health Questionnaire-9
Median (IQR)	8 (7–12)
Range	3–21
7-item Generalized Anxiety Disorder scale
Median (IQR)	6 (4–8)
Range	0–14

IQR = interquartile range.

Qualitative analysis revealed specific contexts in which mindfulness was perceived as most effective. We organized themes that emerged from qualitative analysis using the Who-What-When-Where-Why-How framework popularized as the “5W’s + H” framework in journalism but likely initially conceived by Aristotle (Table 2) (13).

TABLE 2.

Framework of App-Based Mindfulness Intervention Contributing to Recovery

Framework	Theme	Quote	Identifier #	Exemplary Quotes
Who	Participants’ receptiveness to mindfulness influenced their perceptions of its benefit.	1	44	“…If these are people who are new to [mindfulness], then you’ve got to present it in a different way than you would from someone who’s been doing it fifteen years. So, it was not particularly intriguing or new or presented in a special way that made me want to re-up or do anything more than I normally do.”
		2	29	“It was kind of weird for me because I’ve never done any kind of meditation or anything like that.”
		3	35	“I’ve read a lot about meditation…but I had never done anything to see if it would make me feel differently and so this gave me that kick in the fanny, ‘it’s ok’ and it’s helpful.”
What	Participants felt that breathing exercises and mindfulness videos were the most impactful content.	4	11	“Some of the techniques…relax, just breathe in, breathe out, working on focusing your breathing, same focus on certain things…that was very helpful.”
		5	24	“Other things that I’ve adopted from that experience were like some of the most peaceful times of the day were when I was doing my app stuff and doing the breathing and listening to that soothing little computer voice.”
Why	Mindfulness as an intervention had perceived positive effects on physical symptoms.	6	29	“…When I would do [the app]” my blood pressure would go down. I’d just be a whole lot calmer after I got done.”
		7	84	“I was on prednisone in the hospital so I wasn’t sleeping very well and that kind of helped relax me and bring me down a bit so I could rest a little easier.”
		8	46	“It helped me to center my breathing so that I wasn’t short of breath. So, it kept my breathing more steady.”
When/Where	App-based intervention was an important component of a multifaceted recovery process.	9	24	“…I could do it anywhere. I could go outside on the back porch; it was very easy to use.”
		10	75	“I had no energy coming out of [the hospital] and they were like, ‘the best medicine is just to walk.’ So, I walked as much as I could, slept to recover from the walk, and did the breathing exercises, both in the mindfulness app and the doctor prescribed stuff.”
How	Mindfulness intervention delivered via app was convenient and easy to use for most but not all participants.	11	35	“I’m kind of a techno dinosaur…Even for somebody with that kind of experience, it was very easy to use.”
		12	34	“I felt like at least this is straightforward enough for the average person to comprehend.”
		13	5	“I got the same greeting no matter what…you figure out that is what you’re going to get all the time but it’s not helpful.”

Who: Participants’ Receptiveness to Mindfulness Influenced Their Perceptions of Its Benefit

Participants identified that receptiveness to mindfulness as an intervention was an important factor influencing perceived effectiveness. Those who reported extensive prior experience with mindfulness felt the programming was too basic (quotation 1). Conversely, it felt foreign to those with no exposure (quotation 2). Thus, participants who had some intermediate degree of familiarity or preexisting interest described the most benefit (quotation 3). As one participant noted, “if you’re willing to open yourself up to that [app intervention]? Then it definitely helps, as long as you are willing to open up to it…You know your own personality and you know if you’re going to do it or not do it.”

What: Participants Felt That Breathing Exercises and Mindfulness Videos Were the Most Impactful Content

Many participants cited specific content that was most impactful, including breathing exercises and mindfulness videos. This content helped maintain mental clarity and focus on relaxation (quotations 4 and 5). One participant noted the value of breathing exercises “…[to] sit there and take time out to breathe and relax and if you’re feeling any pains or anything so that it doesn’t come out at an inopportune time.” A few participants noted that the content was complementary to exercises recommended for physical recovery, “it’s something I was supposed to be doing anyway, and it was just another coached thing to do that helped with my recovery.”

Why: Mindfulness As an Intervention Had Perceived Positive Effects on Physical Symptoms

The mind-body connection was cited frequently as the main pathway by which the intervention improved perceptions of physical and mental health. For example, one participant noted that “…it taught me to listen to my body, which I had never done before. So now I listen…if I can’t walk three miles today, if I need to stop at one, my body says, ‘you’re done for the day’ its ok, I can do that, so it gives me permission to listen to what I need to hear.” Others perceived positive influences on blood pressure, sleep, and dyspnea symptoms (quotations 6–8). The intervention helped ameliorate anxiety and stress by grounding participants and allowing them to reset their perspectives. This led to self-understanding and normalization of physical and mental symptoms. Participants felt empowered to use the exercises and stress management tools even after the study was completed, one stating “[mindfulness] is a huge contributor to managing stress in daily life.” Others noted an ongoing sense of empathy: “from that experience it kind of helped me be more mindful of others and their struggles rather than just be down in the dumps about yours.”

When/Where: App-Based Intervention Was an Important Component of a Multifaceted Recovery Process

Participants described the timing and flexibility of the app-based intervention to be useful: “I did use the app first thing in the morning. And so it would kind of kick my day off, and then it allowed me the rest of the day, remember what I needed to do to take care of me.” Many noted that they incorporated the app into their daily routines wherever they were, making it a habit along with exercise and rest (quotations 9 and 10). There was a sense that the intervention provided beneficial mental health support during a time of transition after discharge.

In addition, participants described integration of mindfulness techniques with other recovery activities, including cardiac rehabilitation, physical therapy, and individual regimens. As one participant noted as they were coping with hearing loss and balance issues after discharge, “…the physical therapy at that point helped me recognize…and move through that and to me that’s also kind of the mindfulness too. It’s like okay this is the reality.” Several even noted continued use of techniques after the intervention completed and inquired into ongoing app access, “It was a great resource…When I think back on it and what this is doing, I do miss that app and I do miss what we were doing.”

How: Mindfulness Intervention Delivered via App Was Generally Convenient and Easy to Use for Most But Not All Participants

Participants reported several benefits and challenges of the app interface and content that influenced the overall acceptability of the intervention. Several participants described that the app served as a central hub for mindfulness as an intervention. For example, one participant stated “…it gave me all of the information that I needed to be able to start and after that, it was all done on my phone, and I love that part.” Participants appreciated the app reminders, check ins, and structured tasks that encouraged engagement during the busy immediate post-discharge period. One participant explained “…I was sick for a long time before I was hospitalized so the daily reminders, I’m sure were beneficial.”

Although most participants identified that the app had a simple and easy-to-use interface, some described the navigation as nonintuitive and repetitive (quotations 11–13). A small number of participants noted that the content and/or delivery was homogenous and formulaic, making it challenging to detect progression through the program and maintain engagement.

DISCUSSION

In this multicenter qualitative study of ICU survivors’ perceptions of an app-based mindfulness intervention, we identified several themes that highlight how mindfulness may facilitate recovery following critical illness. These include targeting mindfulness strategies toward patients who have prior experience with it and/or are receptive to it as an intervention; structuring the content around breathing and mindfulness exercises; integration with other aspects of rehabilitation; and delivery via an easily accessible modality such as a mobile app. These findings can inform the development and implementation of future interventions to address physical and mental health symptoms and facilitate recovery among ICU survivors.

Our results emphasize specific features that facilitated the mindfulness intervention’s effectiveness in the post-ICU recovery period as perceived by ICU survivors. First, the theme of participant receptiveness suggests an optimal pre-intervention state of exposure to but not expertise with mindfulness in order to appreciate maximal benefit. This is a novel finding that underscores the importance of participant buy-in when designing programs that rely on motivated individuals to engage in mental health exercises. As mindfulness becomes more prevalent in popular culture, future studies may need to consider scaling intervention content based on participant familiarity to maintain engagement. As described in a prior study of the Lift intervention for survivors of COVID-19 hospitalization, which had poor adherence, enrollment, engagement, and retention all play key factors in intervention effectiveness (14). Second, themes regarding the mind-body connection and applicability to other aspects of recovery reinforce the importance of high quality, pragmatic content. The Lift intervention provided highly relevant breathing and mindfulness exercises that participants directly used in rehabilitation programs and daily life even after the intervention was completed. This reinforces findings from a prior study investigating which features of mindfulness-based interventions predict psychological functioning; in particular, practice quality compared with time was a more reliable and durable predictor of psychological functioning (15). Thus, for the ICU survivor population who often has substantial physical and mental rehabilitation needs, the Lift intervention provided optimally tailored and relevant content that contributed to overall recovery.

Insights learned from this study could be readily implemented to address psychological distress and persistent physical symptoms in other medical domains, such as hospital discharge for cardiopulmonary disease, transplant, and the perioperative period. Participants generally felt that the Lift mobile app-based technology was feasible, convenient, and provided necessary structure during a significant period of transition—all mechanisms that could be adapted to complex medical/surgical contexts. A prior meta-analysis of mindfulness-based interventions for surgical patients found some improvement in preoperative anxiety and postoperative pain, demonstrating potential but limited insights into the lived experience of participants (16). Our findings demonstrate how participants with a high degree of engagement in the Lift intervention were able to effectively engage with content and synergize lessons with other facilitators of recovery to reduce psychological distress and physical symptoms like pain and dyspnea.

Moving forward, participants’ perspectives should inform future iterations of the app-based mindfulness intervention to optimize its impact. For example, since participants found synergistic benefit with other forms of recovery, it may be useful to add explicit prompts integrating mindfulness into rehabilitation activities. Given the variability in familiarity with mindfulness, it might also be beneficial to develop an onboarding module and/or adaptive content based on an individual’s prior experience with mindfulness. Methods such as human-centered design could be used to optimize app structure and content in order to better tailor it to the end-user’s specific needs, especially considering that a small number of participants found it difficult to maintain engagement with the content over time. Additionally, as requested by participants, there may be value to extending access to the app beyond the end of the intervention.

Strengths of our study include its multicenter design with regionally diverse representation and focus on the participant perspective. There are also limitations. First, we intentionally sampled patients with more exposure to the intervention given the study’s focus on understanding user experiences. However, this strategy may overrepresent participants’ perceptions of acceptability and perceived benefit, while underrepresenting barriers, nonadherence, and negative impressions of the app. Second, despite efforts to achieve racial/ethnic diversity in the sample, participants were mostly White. Third, inclusion of patients who speak English, as well as the intervention’s reliance on a digital platform, may pose barriers to those with limited English proficiency or digital literacy, respectively. Fourth, the study is at risk of recall bias due to the time delay between the completion of the parent trial and conduction of the study interviews. These limitations may affect generalizability to other contexts including community hospitalization, non-English speakers, and those with lower digital literacy.

CONCLUSIONS

In this qualitative study of ICU survivors who participated in an app-based mindfulness intervention, we identified potential mechanisms through which the intervention improved psychological distress and de-escalated symptoms as perceived by participants. These include a participant’s receptivity to mindfulness as an intervention, the ease and durability of using an app-based intervention on one’s mobile phone, and use of breathing techniques and mindfulness strategies that emphasize the mind-body connection. Our study informs the development and implementation of future app-based mindfulness interventions to address mental and physical health symptoms within the challenging landscape of post-ICU recovery.

Supplementary Material

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