Facilitating Post-Traumatic Growth After Critical Illness

Introduction

Traumatic events are life crises that disrupt the normal patterns of a person’s life and challenge a person’s beliefs and understandings of the world, known as their assumptive world.^1,2 It has long been the notion that psychological, physical, and social distress follow a traumatic event as a person and informal carers/caregivers (e.g., family members, significant others, close friend) attempt to incorporate the trauma into their life.¹ Negatively accommodated trauma (e.g., “the world is out to get me”) can lead to distress characteristic of post-traumatic stress (PTS).² However, following a traumatic event, there are also accounts of people experiencing positive change, which has led to the concept of post-traumatic growth (PTG). Traumatic events displacement of one’s understandings and beliefs offers the opportunity to reexamine pre-trauma self, relationships, his/her philosophy of the world, and to grow new perspectives that incorporate the trauma into reality.³ PTG is defined as the positive psychological growth that can result from effectively coping with trauma.⁴ A new worldview that allows for trauma to be positively accommodated (e.g., “bad things are a natural part of life”) can lead to engagement with social support, to deeper spiritual beliefs, and/or to develop a new sense of self characteristic of PTG. This conceptual review explores the concept of PTG in a critical care population, proposes a role for critical care clinicians in the facilitation of PTG by using strategies to engage patients and informal carers/caregivers, and introduces future directions for critical care PTG research.

Differentiating PTS, PTSD, and PTG

PTG 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 ICU survivors often face unwanted and excessive thoughts of the traumatic event (ICU admission and stay), known as intrusive rumination; feeling out of control of one’s thoughts and situation is characteristic of PTS.⁶ ICU survivors 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 characterizes PTG. Importantly, the theory of PTG does not suggest trauma benefits life or is sufficient for growth, but suggests there is opportunity to understand trauma in such a way in which worldviews grow and new perspectives develop.

Critical Illness and ICU Admission as a Source of Trauma

Trauma is a highly stressful event that uproots a person’s pre-trauma assumptive world.^1,4 ICU admissions, whether the result of an injury (e.g., vehicle collision) or illness, are disruptive in their often sudden and unplanned nature, with a potentially serious risk to health. ICU survivors may experience trauma from multiple sources during an ICU admission, including those that a person deems disturbing and confusing (e.g., hallucinations of abuse or altercations, delirium, awake anesthesia, catheterization, traumatic intubation, disfiguration).^1,8,9 Previous trauma that violates a person’s physical body (e.g., sexual abuse, assault) can prime a patient to experience the physical care in the ICU as a traumatic event (i.e., 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. This can affect both internal personal characteristics and how someone operates in their external world. ICU 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 (e.g., bathing, dressing)^12,17 may contribute to an inability to return to work.¹⁸ One ICU survivor describes life after intensive care as follows:

“I honestly didn’t realize just how many people give up after the traumatic experiences from ICU. The physical and psychological discomfort of cycling between pain and depression felt impossible to escape at times.” [co-author LG]

This 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.

Overview of PTG

The current literature on PTG includes many populations with specific types of trauma or “adversity”.¹ PTG 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, there is evidence of PTG being present with acquired brain injury, an impairment prevalent in many ICU survivors due to physical trauma or delirium,.^29–31

Tedeschi and Calhoun describe PTG as having three broad domains: personal, interpersonal, and existential.^1,22,27 Personally, 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 newfound importance of empathy and good-will towards others. Existentially there are changes in perception of the world, spirituality, religion, and/or philosophy of life.

The extent to which different individuals experience PTG (e.g., ICU survivors, carers) varies.³² Figure 1 is a proposed framework for growth following critical illness (domains informed by Tedeschi and Calhoun, 1996). Traumatic experiences and post-traumatic 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 wildfire³³: the destruction doesn’t 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.

Figure 1-.

Framework for PTG after critical illness

Identifying PTG

The PTG Inventory is a validated measure for quantifying PTG outcomes by assessing five factors associated with the domains of PTG.⁴

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

5. Spiritual development

Because each person who experiences a trauma (e.g., critical illness and ICU admission) is unique and brings their own set of pre-trauma assumptions and understanding of the world, domains of growth and how much growth occurs will vary across individuals.³⁴ For each factor of the PTG Inventory more specific growth outcomes are measured to understand the individual nuances for each person (e.g., compassion towards others, wisdom in understanding of the world).³⁵

Facilitating PTG

Little is known about PTG in survivors of critical illness. However, existing literature in other populations suggests 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 (e.g., 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,^25,34 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 one ICU survivor:

“The resiliency that can result from trauma cannot come without acknowledgement of loss. There is no single correct way to address trauma in each individual struggling to rise from the ashes. Different things will resonate with different people.” [co-author LG]

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

Factors Contributing to PTG

PTSD is the most significant predisposing factor of PTG, thus patients exhibiting signs and symptoms of PTS may be candidates for intervention targeting PTG.³⁶ The presence of social support strongly predicts PTG.^24,36–38 Younger people report higher levels of PTG; it has been hypothesized that younger individuals find trauma more disruptive to their assumed pre-trauma world beliefs, and thus have greater potential for PTG^19,39,40 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.^41–44 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.

Implications for Practice

Post-ICU physical, emotional, and cognitive impairments require specific medical care. ICU clinicians can leverage inpatient and ICU recovery care models to provide relevant services that increase the likelihood of PTG following hospital discharge.

Incorporating PTG into the Inpatient Setting

Tedeschi and Calhoun lay 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 their unique journey as opposed to treating them like “symptoms just to be altered”.⁴⁵ 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 they have experienced previous trauma.¹¹ This information can inform the interprofessional ICU team in order to 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 carers/caregivers is vital to helping the patient cognitively process a traumatic event.⁴⁵ 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 as well as informal carers/caregivers and thus facilitate PTG.⁴⁶

Nurse-Led Inpatient Initiatives

As critical care professionals with the most patient contact hours in the hospital, nurses are crucial in facilitating PTG. We pose 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.

ICU Diaries.

ICU diaries containing details on hospitalization and daily progress can frame cognitive processing of a patient’s trauma.⁴⁷ ICU diaries are written for the patient by the critical care team or family and are associated with decreased anxiety, depression, and PTSD symptoms following critical illness.^41,48 ICU diaries can also serve as a source for deliberate rumination (i.e., conscious thoughts to understand the harmful event and its impact), helping the patient to understand what has happened and how it fits into the their current life.^4,32 This enhanced understanding of the hospital course can facilitate positive incorporation of the patient trauma and contribute to PTG. The cost of ICU diary implementation is minimal compared to the potential benefit of improved patient quality of life.⁴⁷

Family Engagement and Addressing Caregiver Burden.

Nurse-led pre-discharge coaching of family members creates a home environment more conducive to PTG. Support from psychologically healthy family and friends, with 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 can often be frightening, stressful, and have lasting effects on well-being (e.g., depression, anxiety, PTSD).^16,49–52 Family members experience trauma alongside the patient in the hospital, and are often required to quickly transition to carergiver upon hospital discharge. The critical care interprofessional 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.⁵³ 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 carergiver transition while still in the resource-rich setting of the hospital. Early recognition of family member psychological symptoms (e.g., depression, anxiety, uncertainty) can lead to improved carergiver support, and thus enhanced patient PTG, after discharge.

Motivational Interviewing (MI).

MI assesses a patient’s goals and willingness to change pre-hospital assumptions to improve the chance of incorporating positive behavior change after discharge, thus facilitating PTG. MI theory dictates that patients are the ultimate influencers in their own healing.⁵⁴ The key tenets of MI are assessing awareness and readiness to grow, accepting and accommodating a patient’s ambivalence toward change, and maintaining composure during potential ambivalence.⁵⁵ One patient described his nurse-led motivational experience as follows:

“Nurses may need to dial into what drives or motivates patients. Sometimes it can be much easier to have conversations about PTG with someone the patient can identify with or has similar values. When I was in the stepdown unit, one of the nurses brought along another nurse who was a runner and understood how big a loss it would be for me if I couldn’t run again. This example shows the importance of ‘matching’ so patients can work with others who validate their loss instead of skipping ahead to attempts to engender positive growth. Patients may also need to develop new goal setting skills, even if they are already in the habit of goal setting.” [co-author LG]

Rather than direct patients toward clinician-determined goals, MI techniques promote active listening to guide problem identification and to prompt the patient’s motivation toward new goals and growth.⁵⁵ MI’s aim of contemplating and producing behavior change directly addresses a changed sense of priorities post trauma.⁴ MI has been successfully used 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 diabetic patients.^55–58 MI is a cost effective and relevant intervention for nurses to use when communicating with ICU patients. MI can contribute to a patient’s sense of control in their healing strategy, encourage change, and therefore increase the chance of PTG.

Incorporating PTG into ICU Recovery Services

The effects of an ICU admission extend beyond discharge. Therefore, it is vital that patient care continues after the ICU to ensure a safer transition back to life and to aid in the facilitation of PTG. ICU clinicians building relationships with and referring patients to post-ICU recovery clinics can help transition a patient into an environment uniquely structured to further cultivate PTG.

Post-ICU clinics, where available, can serve as 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.^59,60 Post-ICU clinics also aid patients in understanding the physical and cognitive impairments often occurring after ICU discharge, enable recovery, and thus can facilitate PTG.⁶¹ 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 (e.g., case management, pharmacy, medicine, psychology, physical therapy, occupational therapy, palliative care, among others) provided by many post-ICU clinics may directly support and assist the ICU survivor in accessing the five factors of PTG (Table 1).⁶²

Table 1.

Post ICU Clinic Services Supporting PTG Factors of Growth

Provider Category	Service Type	Service Effect	Supported PTG Domain of Growth
Case Manager	Government assistance and DME referrals	Reduce caregiver burden	Fostering more intimate relationships
	Referral to ICU support groups	Opportunity for disclosure
Pharmacist and ICU Clinician	Optimize medication regimens and vaccinations	Reduce readmission and re-exposure to trauma	Greater sense of personal strength
	Referral/coordination with primary care and specialists	Improve physical healing
	Referral to PT/OT services	Reduce ADL dependency
ICU Nurse	ICU diary adjudication	Opportunity for validation	Greater sense of personal strength
Psychologist/ Social Worker	Psychotherapy	Engage patient in deliberate rumination Incorporate the trauma into new life goals and outlook	Greater appreciation of life Changed sense of priorities Recognition of new possiblities or paths in life Spiritual development

ICU=Intensive Care Unit, ADL=activities of daily living, PT=physical therapy, OT=occupational therapy, DME = durable medical equipment; PTG = Post-traumatic growth

Proposed Research Priorities for PTG Following Critical Illness

Survivors of ICU care can experience uniquely high levels of trauma and, we theorize, have the opportunity to build PTG. Based on what we know from other populations and the limited information/research we have on ICU populations, further research in post-ICU PTG has the potential to markedly improve the care of this population. Table 2 details suggested priorities and areas for future research. Pressing needs include understanding what PTG domains (i.e., changes in self, relationships, and philosophy of the world) and trajectories are unique to ICU survivors living with critical 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 carer in fostering PTG also deserves further study. Informal carers/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.^63,64 The role of the informal carer and family in facilitation of PTG during and after the ICU is unknown and empirical investigation could elucidate the impact of the carer/caregiver on PTG.

Table 2.

Proposed research agenda for PTG following critical illness

Topic	Objective	Method
ICU recovery clinics	Do ICU recovery clinic services facilitate PTG from PTSD? If so, how?	Quasi-experimental, Qualitative
Self-help materials for PTG	Test and incorporate structured PTG training for critical care providers, ICU diaries, patient/caregiver resources	Implementation, Quality Improvement, Quasi-experimental
Outpatient vs Inpatient PTG programs	PTG prevalence, timing, and trajectories	Cohort observational
Individual vs Group	Test delivery modalities Evaluate survivor/caregiver preferences	Qualitative, Quasi-experimental
Unique profiles of growth in ICU survivors	Describe domains of growth specific to ICU survivors/caregivers Describe ICU caregiver burden trajectories with PTG	Cohort observational, Qualitative
Therapeutic interventions	Develop and test Mechanism of benefit	Quasi-experimental, Experimental, Patient-centered

PTG = Post-traumatic growth; PTSD = Post-traumatic stress disorder

Conclusion

This conceptual review describes the ICU as a traumatic experience leaving 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 a fire-induced seed sprouts new life after a natural disaster. Due to the intensity and breadth of trauma that ICU patients 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 carers/caregivers to cultivate PTG. Critical care providers and researchers have the opportunity to support ICU survivors as they engage with their trauma and 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.