Introduction
Increasing numbers of survivors of critical illness have also resulted in the recognition of long-term impairments to physical function, mental health, and cognitive function lasting for months to years following critical illness.[1] This constellation of physical, mental health, and cognitive impairments is referred to as post-intensive care syndrome (PICS) with elements prevalent in up to 80% of Intensive Care Unit (ICU) survivors.[2, 3] In addition, family members and support persons for ICU survivors experience a cluster of anxiety, post-traumatic stress disorder (PTSD), and depressive symptoms referred to as PICS-Family (PICS-F).[2] Peer support has been recommended as a novel strategy to alleviate PICS for ICU survivors and family members.[4] Peer support programs provide a community for the promotion of health and well-being for those suffering from PICS and PICS-F via shared experiences of critical illness and recovery.[4]
The purpose of this project was to implement a peer support program at the Nashville Veterans Affairs Medical Center (VAMC) to build an ICU recovery community and provide counseling, stress management, and coping skill development for patients and family members.
Methods
Context
The Nashville VAMC is a tertiary hospital providing care to Veterans in middle Tennessee and southern Kentucky. Nashville VAMC has both Medical and Surgical ICUs equaling 20 critical care beds in total. Beginning in October 2016, we have participated in the Society of Critical Care Medicine (SCCM) international THRIVE Peer Support Collaborative bringing together clinicians implementing peer support programs to improve patient and caregiver outcomes following critical illness.
Intervention
A multidisciplinary team including social work, pastoral care, clinical nurse leader, nurse management, and quality improvement specialist was formed in June 2016 to develop the peer support intervention for a Veteran population. Multidisciplinary planning occurred from June through October 2016. Peer support groups were implemented late October 2016 following an open house to introduce our initiative goals and needs to the executive leadership, faculty, and hospital staff (both ICU and non-ICU providers and nurses). The final structure for peer support group implementation is as follows.
Meeting location.
Factors influencing determination of location of the meeting included transportation options provided by the VAMC, ease of finding location, consistent availability, and promotes comfort and sharing. After discussion of on- and off-site meeting locations it was determined to hold peer support meetings in the medical ICU family consultation room as this was the only comfortable room easily located, consistently available for a standing meeting, and familiar to participants.
Meeting frequency and time.
Staff availability, release time for peer support group meetings, and schedules were important factors in determining meeting frequency and time. We also considered unit turnover and our desire to provide counseling, stress management, and coping skill development to as many potential participants as possible. Upon consideration of these factors, it was decided to have a weekly peer support meeting every Monday at 10:30am.
Meeting participants.
Multiple models of peer support have been reported through the SCCM THRIVE Peer Support Collaborative. Some peer support groups include both patients and family members in one meeting, while others separate patients and family members into different support groups.[5] Additionally, some peer support programs invite only those who have been discharged from the hospital, though others include patients and family members who are still in the hospital.[5] Knowing our patient population comes from a large catchment area with difficulty returning to the hospital for peer support meetings, we decided it was most beneficial to offer our peer support group to ICU survivors and family members together in addition to including those patients (if able) and family members currently in the ICU or still in the hospital.
Group facilitation and format.
The ICU social worker and chaplain both completed training and had experience facilitating support groups utilizing an open, free-flow format for communication that aims to share and normalize the experiences of group participants. Another beneficial feature of this facilitation format is that experienced participants often end up providing support to new group members.[5] Thus this facilitation format was chosen for our support group implementation with the aim to eventually recruit ICU survivors and family members to aid in group facilitation alongside the ICU social worker and chaplain. After 1 year of implementation, a patient (RG) returned for peer support group and has since co-facilitated >10 meetings with the chaplain and social worker.
It was determined the presence of a registered nurse at peer support group meetings could be beneficial in helping patients make sense of ICU memories, answer questions for participants, or provide resources as needed. Finally, 1–2 unit providers (e.g., nurses, physicians) were invited to attend each peer support meetings to facilitate an understanding of the critical illness and ICU recovery experience.
Advertising and recruitment.
Room size and proper facilitation led to the conclusion that a maximum of 6 participants per week is ideal. Flyers were posted in each medical and surgical ICU patient room and large poster boards containing meeting information were placed at ICU entrance (Figure 1). A meeting announcement was also added to the electronic notification system on television screens located throughout the hospital. To recruit participants, the chaplain and social worker informed patients and family members of the peer support group during 1:1 meetings. As a last step, on Monday mornings the clinical nurse leader for each unit reminds all family members in the ICU about the peer support group. Funds were secured in order to provide coffee and snacks as an additional offering to support group participants.
Figure 1.
ICU Recovery Group Flyer
This flyer was developed by the multidisciplinary team and displayed throughout the Nashville VAMC.
Measures
Support group uptake was measured as the number of participants attending each support group meeting. An 11-item support group evaluation survey informed by the Domestic Violence Evidence Project was developed to assess acceptability and usefulness of our peer support program.[6] (Full survey available as Electronic Supplement 1) Free form comments were invited as the final item on the evaluation survey. The voluntary anonymous surveys were distributed at the conclusion of each peer support group meeting.
Analysis
Descriptive statistical summaries are utilized to report evaluation survey responses. Statistical summaries were developed using Microsoft Excel. Qualitative feedback from peer support participants were evaluated and verbatim comments supporting survey descriptive summaries are provided.
Ethical Considerations
The project was reviewed by the Nashville VAMC Institutional Review Board and it was agreed that this work was quality improvement and, thus, not subject to ethics approval.
Results
From October 2016 through September 2019, total support group attendance is n=268. Median weekly support group attendance n=3 (interquartile range 2, 4). The evaluation survey response rate was 40% (n=106). Of evaluation survey respondents, 6% (n=6) attended more than 2 peer support meetings. The majority of survey respondents (94%, n=100 ‘very much’) reported attending the peer support group made them feel emotionally supported and helped them learn from other ICU patients and families on how to best cope with the current situation. A lesser proportion (76%, n=81 ‘very much’) reported having a better understanding of common situations related to prolonged stays in the ICU and critical illness. Respondents (61%, n=65 ‘very much’) reported peer support participation helped them to plan for their wellbeing during recovery and 63% (n=67 ‘very much’) know more about community and VA resources to help with recovery. Less than half (47%, n=50 ‘very much’) of respondents felt more in control of their life than before starting the peer support group. Lastly, few survey participants (36%, n=38) reported a ‘very much’ interest in volunteering to support other families in need at some time point in the future. Most survey respondents (85%, n=90) would strongly recommend peer support group participation to a friend.
Open-Ended Survey Responses
Participants reported the peer support group as being “wonderful”, “very encouraging, brings more of a peace”, and “very helpful knowing what to expect”. Some participants did not realize they needed the group until attending their first meeting.
“…the hurt caregiver are in need of more support. There is a lot of help the caregiver does not know until you to a meeting. A lot of information was given that I feel the caregiver should know.”
“I was asked to come and now I feel like I really can do it. Enjoyed sharing with the group. I am not alone.”
An overwhelming theme of support group participation was feeling supported by knowing you are not alone in your struggles of critical illness and recovery.
“It was very helpful and reassuring to know we were not alone with what was going on.”
“It helps not to feel alone.”
“It is so healing to talk with other people who have the same challenges---strength together.”
“We need to know that we are not along and that there is strength in this group.”
“It’s calming to experience that you are not alone and that you want to do the right thing for yourself and your loved ones. You an open up your heart and expel all the fears and pain that you have.”
Peer Support Group Influence on ICU Culture
Implementation of the peer support program at this VA hospital has changed the ICU culture to be more supportive of patient- and family-centered care. On a weekly basis, our team saw the value of human connection and empathy during critical illness. Too often, the humanity of the patient is missed, and providers forget that every patient has a story. Staff saw that the person in the corner of the ICU room was more than a body occupying space. This person was a wife, a mother, a child, or a friend full of emotions and fears, who are experiencing their own crisis. Prior to implementing our peer support program, this was not readily recognized. The peer support group provided our staff with insight into the perspective/experience of family members/friends and created a humanizing effect. We became better at connecting with families, recognizing their needs, and involving them in daily care of the patients.
Implementation of the peer support program also helped to bring joy to the nursing staff. Nurses and other providers were rewarded by seeing how the peer support group was positively impacting family members. Staff also began to create special bonds with patients and family members. More so now than in the past, patients and family members return to the ICU after discharge to express their gratitude for the support they received during their critical illness admission.
Discussion
The Nashville VAMC was able to successfully create a community for the promotion of health and well-being for those suffering from PICS and PICS-F via implementation of a peer support group program for critically ill Veterans and their family members. In conjunction with the SCCM THRIVE Peer Support Collaborative we have successfully sustained our peer support program for three years with a median of three participants per meeting. Our peer support program appears helpful in increasing patient and family member support for ICU recovery. Facilitation by a trained social worker and chaplain lent to the quality of peer support provided. Lastly, support from managing directors and ICU leadership for staff time lent to the stability and sustainment of our peer support program.
Implementation of the peer support program was the beginning of a new culture within the Nashville VAMC ICUs focused more intently on engaging with patients and family members more empathetically. Nurses and physicians described having a more real-life understanding of the suffering family members and patients experience during and ICU admission and while recovering from critical illness with ongoing physical, cognitive, and mental health impairments. Moreover, a number of VA staff and leadership began attending the meetings not as an observer, but as a participant in need of peer support for a personal ICU experience.
An ICU Survivor’s Perspective
A key strength of our peer support program is the involvement of an ICU survivor as facilitator for peer support. Mr. Gervasio’s initial weekly attendance with the peer support group focused on his own cognitive issues which allowed him to knit together things he could remember with those he could not. Ralph describes having issues during recovery, but they felt surmountable. Approximately one year after his first meeting, with his words coming out in the right order and with gratifying reassurances and support from the chaplain and social work facilitators, he attended not for himself, but for others. Per Ralph, so many patients have family members who need support and a break from the pressures of their loved one in a bad state. He offers himself as a survivor who can relate the effects of ICU delirium and other oddities the family members do not understand. He went through an ICU experience. Through his involvement in the peer support program, Ralph has become an incredible model of someone who has treated his recovery as an opportunity to give back. He inspires others in the ICU to help overcome barriers to patient- and family-centered care and clear misconceptions about ICU recovery. Ralph adds the following:
“When professional staff and clergy stopped short of asking deeply personal and poignant questions to support group participants, I had a more freedom, being an ICU ex-patient survivor and non-professional, to tap into the raw emotions of those who otherwise felt remiss to offer their true feelings. Often my comments/questions spurred other PICS-F participants to speak more freely, having seen one member emote and thus wanting to support that person by sharing as well. I believe a veteran ICU survivor can sense through non-verbal cues when and how to extract acute feelings from affected family members. I worked closely with my medical, social work, and pastoral partners for two-and-a-half years, to give back to those who gave me a second chance at life while helping others cope with the acute stress of having a loved one in the ICU.”
Ralph Gervasio, Vietnam veteran and Medical ICU survivor
Limitations
A limitation of this reported work is the single center implementation of a peer support program at a VA hospital. Implementation in other contexts may require different processes, procedures, and approvals. However, we feel that providing details of our implementation decision-making process and final procedure will help others to develop a program that can work in their own context. Next, we did not evaluate whether symptoms of PICS and PICS-F are reduced by participation in our peer support program and this needs to be done in future study. Finally, we have had the same multidisciplinary team overseeing and facilitating the peer support program since inception. Though we have sustained the program for three years, it is unclear how turnover in the implementation team will influence sustainment.
Conclusion
We have developed a feasible and sustained process for peer support in the ICU and are now evaluating spread of the peer support program to the sister hospital in our middle Tennessee VA healthcare system. Our peer support group gave families a chance to tell a patient’s story in a warm and supportive environment. ICU survivor peer presence helped family members hear from the perspective of a patient and gave great insight to what their loved one might be facing while being treated for critical illness. The multidisciplinary approach of having a chaplain, social worker, and nurse present to lead the peer support group provided a well-rounded and team-centered approach to care. Ultimately, the peer support group added significant value to the ICU experience by giving both family members of current patients and ICU survivors a chance to share stories while giving and receiving support.
Future research could focus on efficacy of peer support programs in reducing the mental health impairments associated with PICS and PICS-F and implementation strategies for sustained peer support group implementation. However, given the small numbers reported at each institution, a multisite project would be necessary to detect significance. The post-ICU primarily nurse-led support group intervention was implemented with minimal financial resources and is offered as a replicable method of enhancing patient and family member recovery from critical illness.
Supplementary Material
Figure 2.
Peer Support Group Evaluation Survey Findings
11-item voluntary survey administered anonymously to peer support group participants.
KEY POINTS.
List 3 to 5 key points of approximately 25 words each that summarize the main points of the article. Key points appear beneath the article title and authors in print and online
Post-intensive care syndrome (PICS) is decidedly prevalent among ICU survivors.
Peer support programs are a recommended method to alleviate the anxiety, PTSD, and depressive symptoms associated with PICS.
Implementation of a peer support program at a Veterans Affairs hospital was well-received by patient and family member participants.
SYNOPSIS.
Peer support has been identified as a novel strategy to mitigate Post-intensive care syndrome (PICS) and PICS-Family. The purpose of this project was to implement a peer support program to address PICS and PICS-F by providing patient and family support during and following critical illness. Using a free-flow, unstructured format, a chaplain, social worker, nurse, and ICU survivor led Veterans and loved ones in discussion of ICU experiences, fears, and the challenges of recovery during scheduled peer support sessions. Evaluations indicated group participation is very beneficial for emotional support, coping, and understanding common situations related to prolonged ICU stay. A majority, reported they would strongly recommend group participation to a friend.
DISCLOSURE STATEMENT
LMB is currently receiving grant funding from NHLBI (#K12HL137943-01). The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The contents of this paper are solely the responsibility of the authors and do not necessarily represent those of the National Institutes of Health, the Department of Veterans Affairs or Vanderbilt University.
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Associated Data
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