Healthcare Professionals’ Perceptions of Patients’ Out-of-ICU Activities: Exploring Opportunities for Humanizing ICU Care

Abstract

Patients hospitalized in an intensive care unit (ICU) are vulnerable to dehumanization. To provide ICU patients and their family members with more enjoyable and meaningful ICU experiences, our hospital has implemented out-of-ICU activities, including outdoor excursions and whole-body shower bathing as an early rehabilitation strategy. Herein, we investigated healthcare professionals’ perceptions regarding how these out-of-ICU activities affect both the patients’ physical and mental conditions and the humanized care of ICU patients. We conducted a survey that asked 17 questions (benefits, harms, “What if you or your family member were the one in the ICU?” and humanization) and provided a free-writing section. Thirty-six physicians, 38 nurses, 9 therapists, and 7 clinical engineering technicians responded (84% response rate). Most respondents perceived that the out-of-ICU program improves patients’ conditions and promotes humanized care in the ICU. These preliminary findings provide valuable insights, though larger and more rigorous studies are needed to confirm and extend the results.

Keywords

clinician–patient relationship quality improvement patient- and family-centered care early mobilization humanization

Introduction

Patients treated in an intensive care unit (ICU) are vulnerable to dehumanization, as they are often deprived of positive human qualities such as dignity and respect and are treated as a “group of symptoms” rather than as unique individuals.^1–3 One of the main reasons for this potential dehumanization is the human tendency to dehumanize an individual who is different from themselves.^1,4 ICU patients are markedly different from medical staff because they are often unable to express their feelings or intentions and/or are dependent on life-supporting machines. Moreover, dehumanization occurs as a self-defense mechanism for medical staff to cope with the psychological stress brought on by empathy.^1,2,4,5

In a medical setting, the concept of humanization refers to human-centered care that considers and honors human identity, respects human dignity, and empowers all individuals, including patients, their family members, and healthcare professionals.^1,2,4,6,7 Family involvement, effective communication, and creating outdoor spaces for ICU patients have been promoted as part of humanizing intensive care.^8,9

For the past 10 years, we have conducted an out-of-ICU activity program that includes indoor excursions, outdoor garden visits with family, and whole-body shower bathing, and we reported the program's safety.¹⁰ The program appears to provide both ICU patients and their family members with more enjoyable and meaningful experiences, contributing to humanized healthcare. The aim of this research was to explore healthcare professionals’ perceptions of how out-of-ICU activities affect ICU patients’ physical and mental outcomes and the humanization of care, as well as the impacts on healthcare providers’ workload. We also examined potential differences in the perceptions among the medical professions.

Methods

The single-center, cross-sectional survey was conducted with multidisciplinary healthcare professionals between January and December 2022 at a teaching hospital.

As part of standard care for ICU patients, a multiprofessional team assesses each patient's hemodynamic and respiratory stability and body temperature every weekday morning and discusses which mobilization practices, including out-of-ICU activities, can be implemented that day. The accepted plan is then explained to the patient, and the patient's agreement is obtained. An intensivist, an ICU nurse, and a physiotherapist (and sometimes additional staff) are assigned to the activity. When the patient is mechanically ventilated, a clinical engineering technician (CE tech) joins to manage the ventilator.

The subjects of this study were physicians (Drs) whose patients had participated in the out-of-ICU program, ICU nurses (Nrs), physical and occupational therapists (P/OTs), and CE techs who had participated in the activities. The study's semistructured survey collected the participants’ demographics, 17 Likert-scale questions (1, strongly disagree; 2, disagree; 3, neutral; 4, agree; 5, strongly agree) about benefits, harms, and humanization, and provided a free-text section. Paper surveys were distributed, completed anonymously, and collected anonymously. The Institutional Review Board (IRB) waived written consent, as answering and submitting the survey was considered consent, as stated in the survey. This study was approved by the IRB.

Statistical Analyses

The Likert scale scores were calculated and are expressed as a distribution percentage, and the mean scores and standard deviations were examined by profession in questions about benefits and harms. The normality and homogeneity of the data's distribution were verified by the Shapiro–Wilk test and Levene test, respectively. A one-way analysis of variance with Tukey's post hoc test was performed to assess the significance of differences between the 4 profession groups. For nonparametric analyses, the Kruskal–Wallis test and Steel–Dwass multiple comparison test were performed to compare differences between the groups. Statistical significance was set at p < .05. The statistical analyses were performed using R 4.3.3 (CRAN, freeware), and the Steel–Dwass multiple comparison test was conducted using the NSM3 package.

Results

Of the 107 eligible professionals (43 Drs, 48 Nrs, 9 P/OTs, and 7 CE techs) invited to participate, 90 completed the survey (36 Drs, 38 Nrs, 9 P/OTs, and 7 CE techs; Supplement Table 1), giving an 84% response rate. No data were missing.

The Survey's 17 Questions

The scale score distributions for each question are shown in Supplement Table 2.

Benefits and Harms of the Out-of-ICU Program

More than 82% of the respondents scored 4 or 5 on each positive question, and fewer than 14% scored 4 or 5 on each negative question, indicating overall favorable opinions toward the program.

The profession-specific analysis revealed that all 4 professional groups had mean scores >3 for all positive questions and <3 for negative ones, except for Q9 (hindering other duties), where P/OTs’ mean score was 3.2 (not statistically significant). Similar scores were observed across professions for Q2 (mitigating delirium), Q5 (improving patients’ general condition), Q6 (exacerbating patients’ general condition), and Q10 (alleviating family members’ stress). Significant group differences emerged as follows.

On Q1 (improving patients’ physical function), the CE techs scored significantly lower compared to the Drs. Concerning Q3 (alleviating psychological stress), the CE techs scored significantly lower than all other groups. For Q4 (promoting motivation), the Nrs and the CE techs scored significantly lower than the Drs. In their responses to Q7 (having observed deterioration in a patient's condition), the Nrs’ scored significantly higher than the Drs. Regarding Q8 (the out-of-ICU activities program should be abolished for safety reasons), the CE techs scored significantly higher than the Drs, although their scores were still <3, indicating that the CE techs did not think that the program should be abolished.

Hypothetical Question: “What if you or Your Family Member Were the one in the ICU?”

More than 80% scored 4 or 5 on Q11–Q13, indicating that if they themselves were to be hospitalized in the ICU, they would want to visit the outdoor garden, visit the garden with family, and take a bath. Over 90% scored 4 or 5 on Q14–Q16, indicating that if their family member were hospitalized in the ICU, they would want the family member to participate in the activities.

Humanization

On Q17, 95% scored 4 or 5, stating that the out-of-ICU program helps promote humanized care in the ICU.

Free-text Responses

Representative comments are shown in Table 1. All groups mentioned that the out-of-ICU program helped ease the stress of both patients and family members. The Drs expressed only positive opinions, including “…and (it) actually helped the medical treatment itself, because the patients and their relatives became more positive toward the treatment” (D1), and they encouraged us to continue this program (D2). The other 3 groups expressed some concerns.

Table 1.

The Free-Text Responses.

All professionals’ comments

During the pandemic when there was a visitation ban, this out-of-ICU program was really helpful for easing the stress of both ICU patients and their family members.

Physicians’ comments

This is a wonderful opportunity for both patients and their families, and actually helped the medical treatment itself, because the patients and the relatives became more positive toward their treatment. (D1)

I’m sure that it takes time and effort, but please continue this endeavor. (D2)

One delirious patient regained sanity after an outdoor garden excursion. (D3)

One patient said, “I’m tired,” after an outdoor excursion or bathing, but he showed a very satisfied look. (D4)

This is really meaningful for both patients and their families, but I’m concerned that it may increase the workload for the members. (D5)

Many patients request to go take a bath again, so it must be really refreshing and relaxing. (D6)

ICU nurses’ comments

This is a great program of true multiprofessional teamwork with outstanding specialists. (N1)

We can see the patient's expression that we would never see in the ICU. This is really rewarding. (N2)

Sometimes it's hard, especially when it's very busy, but seeing that the patient and their family members are so happy to see each other in the garden, I always feel that I’m glad that I did it. (N3)

One elderly patient met a grandchild in the garden and showed a big smile as Grandpa, even though he was intubated. Seeing that, I recognised that he is a person who has a family, not just a patient. (N4)

Sometimes, family members say “Thank you” to us with tears when we are in the garden. (N5)

I sometimes wondered how the patients really feel about this program. It might be a pain for some patients. (N6)

Once, a patient expressed that he didn’t want to be seen when he was so weak. (N7)

Physical/occupational therapists’ comments

This program does have some risks, but thanks to multiprofessional collaborative practice, we therapists can mobilize patients safely. (R1)

Sometimes patients refuse the out-of-ICU activity. At times like that, I’m torn between the benefits of the program and respect for the patients’ preferences. (R2)

In the ICU, members collaborate for mobilization, so we can do it. But in a regular ward, I’m all alone and cannot provide the same level of rehab. (R3)

Clinical engineering technicians’ comments

I need to make sure to prepare a portable ventilator, an oxygen tank, a monitor, etc, for the sake of the patient's safety, because we’re going out of the intensive care environment where everything is ready. (C1)

Some patients may feel pain, I guess. (C2)

Abbreviation: ICU, intensive care unit.

One nurse wrote, “Once a patient expressed that he did not want to be seen when he was so weak” (N7). Another wrote, “It might be a pain for some patients” (N6). One P/OT wrote, “Sometimes patients refuse the session. At times like that I’m torn between the benefits of the program and respect for the patients’ preference” (R2). One CE tech noted, “I need to make sure to perfectly prepare a portable ventilator, an oxygen tank, etc. For the sake of patients’ safety, because we’re going out of intensive care environment where everything is ready” (C1).

Discussion

We conducted an exploratory, perception-based inquiry of 4 healthcare professional groups at a teaching hospital to identify their perceptions of the out-of-ICU activities regarding patients’ benefits and risks, and the professionals’ workload. The results indicated that they perceived the program as beneficial for humanizing ICU patients and for improving ICU patients’ physical and mental conditions.

ICU patients are profoundly susceptible to dehumanization^{1,2,6,7,11,12} as their agency is impaired since they often cannot express their feelings or intentions and are dependent on life-supporting machines, which makes them markedly different from the healthcare providers. This dissimilarity is one of the main causes of dehumanization.^1,4 Most respondents noted that the out-of-ICU activities promote humanized care. This may be not only because the program provides better services to patients and their families, but also because the healthcare providers involved in the program felt closer to the patients, as they recognized that the patient is a “person” (N4) and not just a “case” while observing heartful interactions between patients and families in the open-air space, and thus felt rewarded (N2, N3) (Table 1).

High-quality contacts between patients and healthcare professionals, which enhance physical or emotional proximity, are considered one of the most reliable ways to counteract dehumanization because increased physical and psychological distance are key contributors to dehumanization.¹ Information boards describing the patient, such as the Get to Know Me Board (GTKMB)¹¹ and Footprints (FP),¹² were reported to be an excellent intervention to promote humanized care by preserving the patient's personhood, fostering communication, and building better relationships between patients/their families and healthcare providers.

Providing proper hygiene and comfort to patients is another important factor of humanized care.² Most ICU patients who had a whole-body shower bath requested to take such a bath again, and they appeared relaxed and often fell asleep after a bath. Baths also gave family members and staff positive feelings, as the patient's skin was soft and clean with a pleasant scent.

We found no major differences among the professional groups’ perceptions. This may reflect the culture of multiprofessional collaboration that has supported the program for over 10 years without major adverse events.¹⁰ However, our research group previously reported some transient adverse physiological changes, such as increased oxygen requirement or vasopressor dose, or tachypnea. As the patients’ safety is paramount, an experienced intensivist must accompany each session as a team leader, monitoring the patient closely and intervening if needed. This program requires meticulous preparation and coordination among the professionals. Each team member must be well-trained regarding the out-of-ICU activities and cooperate with other team members based on an understanding of the other members’ roles to ensure safe implementation. We currently accept patients’ verbal or gestured agreement rather than a formal written consent for the activities. However, obtaining written consent would be appropriate if required by institutional policy. In addition, as some nurses noted, certain patients may feel discomfort during the activities (N6, N7) (Table 1). Every patient is unique, with individual preferences, history, and goals, and healthcare professionals must respect these values.

The out-of-ICU activity program has thus provided a valuable platform for loving and cordial patient–family–professional encounters. Based on our findings, we propose the hypothesis illustrated in Figure 1: the out-of-ICU activity program fosters humanized intensive care by helping healthcare professionals recognize that “the patient is a human being just like us” and promotes a cycle of humanization in healthcare. As shown in Figure 1, there are 2 main different approaches. The first, education (A), focuses on dos and don’ts—fostering empathy, respect, and compassionate care by avoiding dehumanizing behaviors (eg, referring to patients by disease name or room number and talking over patients) and by encouraging humanizing behaviors (eg, using the patient's preferred name and responding promptly to needs).^2,4,6–8,11 The second, human connection (B), is fostered through out-of-ICU activities, GTKMB,¹¹ FP,¹² or even a photo showing the patient's life before hospitalization.² These approaches create opportunities for personal connection and remind professionals that the patient is a person. These strategies may be especially valuable in institutions with staffing or logistical barriers to outdoor activities, providing alternative means to promote humanization.

Figure 1.

Hypothesis of humanization in healthcare and the role of out-of-ICU activities. 1. Healthcare professionals recognize the patient as a human being. 2. This recognition fosters empathy, respect, and compassionate care. 3. Compassionate care promotes positive interactions and human connection among patients, families, and professionals. 4. Through these human connections, professionals further acknowledge the patient’s personhood. This cycle promotes humanization in the healthcare system. Out-of-ICU activities serve as a platform for meaningful patient–family–professional encounters, thereby accelerating this cycle.

Study Limitations

There are several study limitations to address. First, this was a perception-based study of healthcare professionals. We did not evaluate the ICU patients’ perceptions of the program or those of their family members, and we did not investigate the patients’ physical or mental outcomes or the program's humanizing effects on the patients. Second, this was a small-sized single-center survey, and the results may thus not be generalizable. Third, we cannot exclude the possibility of response bias, as the survey respondents may have had a more favorable opinion toward the out-of-ICU program, although the response rate was high at 84%. Fourth, we created the survey; it is not a validated measurement tool. There may be other positive or negative aspects that were not addressed. Fifth, the survey was conducted by an intensivist, and it is possible that this may have had some influence on the positive reactions toward the out-of-ICU program. Overall, these findings provide important preliminary insights, but larger, multicenter studies using validated tools and including patient and family perspectives are needed to confirm and extend these results.

Conclusion

Our multiprofessional survey revealed that 4 types of healthcare professionals felt that the out-of-ICU activity program is beneficial for ICU patients’ physical and mental care and humanizes intensive healthcare. Future studies that elucidate the effectiveness and the underlying psychosocial mechanisms of this program for patients, family members, and healthcare providers are warranted, and quality-improvement projects from the perspective of humanization would be worthwhile to extend our present findings.

Supplemental Material

sj-pdf-1-jpx-10.1177_23743735251383260 - Supplemental material for Healthcare Professionals’ Perceptions of Patients’ Out-of-ICU Activities: Exploring Opportunities for Humanizing ICU Care

Supplemental material, sj-pdf-1-jpx-10.1177_23743735251383260 for Healthcare Professionals’ Perceptions of Patients’ Out-of-ICU Activities: Exploring Opportunities for Humanizing ICU Care by Nobuko Sasano, MD, PhD, Masami Yasuda, PT, Ryoko Takahashi, RN, and Toru Uehara, PT, PhD in Journal of Patient Experience

Supplemental Material

sj-pdf-2-jpx-10.1177_23743735251383260 - Supplemental material for Healthcare Professionals’ Perceptions of Patients’ Out-of-ICU Activities: Exploring Opportunities for Humanizing ICU Care

Supplemental material, sj-pdf-2-jpx-10.1177_23743735251383260 for Healthcare Professionals’ Perceptions of Patients’ Out-of-ICU Activities: Exploring Opportunities for Humanizing ICU Care by Nobuko Sasano, MD, PhD, Masami Yasuda, PT, Ryoko Takahashi, RN, and Toru Uehara, PT, PhD in Journal of Patient Experience

Footnotes

Author Contributions

NS designed the study, applied for and acquired the IRB permission and funding, and wrote the manuscript. MY and RT collected the data and interpreted the results. TU statistically analyzed the data.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Approval

This research was approved by the IRB of the Nagoya City University East and West Medical Center (approval no. 21-04-385-39).

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by JSPS KAKENHI (grant number 23K08446).

Informed Consent

The requirement for written consent to participate in this study was waived by the IRB, as answering and submitting the survey was considered consent to participate, as was stated in the survey.

ORCID iDs

Nobuko Sasano

Toru Uehara

Supplemental Material

Supplemental material for this article is available online.

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