Multidisciplinary team perception of games-based therapy in critical care: A service evaluation
Funding information: Owen Gustafson, Clinical Doctoral Research Fellow (NIHR301569) is funded by Health Education England (HEE)/National Institute for Health Research (NIHR). Sarah Vollam and Elizabeth King were supported by the NIHR Oxford Biomedical Research Centre. The views expressed are those of the authors and not necessarily those of the NIHR, NHS, or the UK Department of Health and Social Care.
Abstract
Background
As survivorship following critical illness improves, there is greater focus on maximizing recovery. As well as physical effects, critical illness often results in cognitive impairments such as delirium, anxiety, or disorientation. In other populations, such as delirium, non-pharmacological approaches to manage these conditions are preferred, including re-orientation and ensuring personal care needs are met. Cognitive rehabilitation is also well documented for patients with neuropsychological deficits. Treatments include memory aids, compensation strategies, and functional execution. In other hospital populations, games and activities have been utilized to optimize patient engagement, stimulation, and aid recovery, but it is considered an emerging therapy in intensive care.
Aims
This service evaluation aimed to gather multidisciplinary team members' perceptions of the use of games based therapy (GBT) in critical care, including patient engagement and acceptability in clinical practice.
Study design
A UK-based single-centre qualitative service evaluation. Purposive sampling was used to identify interviewees within an adult intensive care who had experience of using a recently implemented GBT intervention. Qualitative data were collected through semi-structured interviews, which were recorded and transcribed verbatim. Data were analysed using thematic analysis.
Results
Eight staff members across the multidisciplinary team were interviewed. One overarching theme of humanizing health care was identified, with three sub-themes of enhancing recovery, non-physical components of care, and bespoke tailoring. In addition, further recommendations for development of the service were summarized.
Conclusion
GBT was well received by staff in clinical practice. It was described as a supportive adjunct to traditional care and rehabilitation, enhancing staff-patient relationships. While it was recognized it may not suit all patients, GBT has the potential to enhance cognitive and physical recovery.
What is known about this topic
- Non-pharmacological strategies should be considered as first-line treatment of delirium and non-physical morbidity.
- Low fidelity, recreational activities have been utilized in the general inpatient populations to stimulate cognitive function.
What this paper adds
- In our service evaluation, staff described the use of games based therapy as facilitating humanization of critically ill patients.
- Staff also identified the potential for games based therapy to aid optimization of recovery from critical illness in terms of non-physical morbidity and can contribute to physical rehabilitation.
1 INTRODUCTION
As survivorship following critical illness improves, there is greater focus on maximizing recovery.1 Critical illness often results in both physical and cognitive impairments such as delirium, anxiety, or disorientation.2, 3 Delirium is commonly exacerbated by environmental factors including sleep deprivation, noise levels, and lack of cognitive stimulation.4 Critical care nurses support patients' care needs at the bedside, ensuring patient-centred care and advocating for the patient across the multidisciplinary team (MDT).5 They are pivotal in readily recognizing changes in patients' clinical status. Critical care physiotherapists work closely with the nursing team to deliver respiratory care and early mobilisation,6 while occupational therapists concentrate on cognitive and functional rehabilitation. Together, the MDT aims to optimize biomedical care, restore function, and enhance patient experiences. It is widely recognized that non-pharmacological approaches are the first line to manage delirium by improving cognitive function through cognitive stimulation, memory rehabilitation, orientation, and neuropsychological rehabilitation, and specifically improving functioning capacity for patients, such as activities of daily living.7 In particular, multi-component non-physical interventions were effective in preventing delirium in older patients with focus on staff education and re-orientation protocols.8 A study inclusive of adults 70 years and older admitted to hospital used orientation and therapeutic orientation as components of an extensive model of care to prevent cognitive decline, but identified this does not need to be undertaken on a dedicated generic unit.9 Cognitive rehabilitation is also well documented for patients with neuropsychological deficits. These deficits affect memory, attention, spatial perception, and language, commonly in patients with stroke or traumatic brain injuries. Traditional treatments include memory aids and compensation strategies, with more recent focus being on the transition into functional execution.10-12 Similar clinical presentations can be experienced by patients during and following critical illness. Few studies have explored recreational games based therapy (GBT) style interventions. Within intensive care units (ICU), physiotherapists have used interactive video games to optimize balance and endurance, and this is deemed safe.13, 14 In geriatric settings, the provision of board games has been shown to be cognitively stimulating and reduce depression.15 In other hospital populations, games and activities have been utilized to optimize patient engagement, stimulation, and aid their recovery, but it is considered an emerging therapy in intensive care. To our knowledge, the use of non-technological activities has not previously been evaluated in ICU.
2 AIMS
This service evaluation aimed to explore MDT members' perceptions of the use of GBT in critical care, including patient engagement and acceptability in clinical practice, to inform future development of the intervention.
3 DESIGN AND METHODS
To ensure transparency, this service evaluation was reported following the Standards for Quality Improvement Reporting Excellent (SQUIRE) guidelines along with relevant aspects of the Consolidated for Reporting Qualitative Studies (COREQ) guidelines in reference to the qualitative approach taken for this project.
3.1 Setting and sample
This service evaluation was conducted in the Adult ICU of a large tertiary referral centre in the United Kingdom, admitting patients with medical, surgical, and trauma specialities.
Purposive sampling was used to explore the knowledge and experience of those with exposure to GBT.16 To optimize data richness,17 it was important to understand the thoughts of those who had direct engagement or observation. Therefore, participants from across the MDT were sought. Staff were eligible to participate if they were a member of the ICU team where the service evaluation was based, and had experienced the GBT intervention in clinical practice.
Although no absolute guidelines on qualitative sample sizes exist, guidance suggests a sample of 6 to 10 participants as potentially sufficient for a small, focused single-site study.18 In addition, it was intended that data collection would cease when no new codes were generated for staff interviews. While data saturation is not truly aligned to thematic analysis methodologies, this allowed for a general assessment of the sufficiency of the sample.19
3.2 Trustworthiness
Several approaches were taken to ensure trustworthiness during this project.20 In conducting qualitative interviews, it is important to consider reflexivity.21 EK was a critical care physiotherapist seconded to a split clinical and research role at the time of data collection. SV is an experienced critical care nurse researcher who has experience in clinical practice and has a wealth of research training. Researchers provided written reflections after each interview, including observations on rapport, circumstances during the interview, and any potential biases. As EK worked directly with all the interviewees, SV conducted three of the interviews with the therapy team, offering an ‘outsider’ perspective with the aim of ensuring staff felt able to talk honestly about their experiences of GBT.22 Furthermore, multiple researchers in collecting and analysing the data, and regular team meetings to discuss developing themes and acknowledge potential sources of bias, added to the validity of the results. Furthermore, concurrent data collection and analysis allowed identification of data saturations, when no new codes were being identified during analysis.
3.3 Intervention
The GBT intervention consisted of jigsaw puzzles, word searches, colouring books, small games, and activity cards. The implementation of GBT was promoted through posters, e-mail communication, and informal MDT education sessions on the unit. The GBT activities were stored in an accessible location on the ICU, and the MDT education sessions were encouraged to use them independently. All activities were wiped down with appropriate clinical wipes following use. There were no formal pre-requisites for the patient selection for GBT, but from a practical perspective, they needed to be alert and engaged. Patients identified as suitable for the therapy were commonly experiencing boredom, symptoms of delirium, and had prolonged ICU stays.
3.4 Data collection
Semi-structured interviews were conducted to explore staff experiences of GBT. Use of a topic guide allowed exploration of key questions related to GBT implementation while allowing participants to discuss what was important or relevant to them, see Appendix S1. The topic guide was developed using a five-step framework ensuring methodological robustness.23 Piper et al advocated semi-structured interviews as a powerful tool for examining practice approaches within critical care research,24 reflecting the aim of this service evaluation.
Eligible staff were invited to participate through team e-mails, posters, and approach by researchers. It was made clear that participation was voluntary. All interviews were conducted in a quiet room away from the ICU and lasted between 10 and 33 minutes. Reflexive notes were taken during and after the interviews. Recordings were transcribed verbatim and anonymized.
3.5 Data analysis
Thematic analysis was selected as the most appropriate approach for the pragmatic aims of this service evaluation, and followed the six phases outlined by Braun and Clark.25 Thematic analysis allows for the identification of themes and patterns of meaning across the data.18 Importantly, it is considered as an active process as the codes and then the themes are developed and refined. Analysis of interview transcripts was supported by NVivo 11 (NVivo qualitative data analysis software; QSR International Pty Ltd. Version 11). In phase one—familiarization with the data—EK listened to and transcribed each recording. Analysis then proceeded to Phase 2, with EK examining a portion of the transcripts (with guidance from SV) and assigning codes to portions of the text, which identified an aspect relevant to the project aim. These initial codes were discussed between the research team and developed into a preliminary coding tree of 5 parent and 23 child nodes. Through peer view of the coding tree, EK along with SV, OG, and TJ developed and agreed on the initial themes (Phase 4). Coding continued for the remaining transcripts and themes were further developed, refined, and finalized within the team (Phases 4 and 5). A report of themes and sub-themes was written by EK and SV, and refined by the whole team (Phase 6).
4 ETHICS STATEMENT
Advice was sought from the Research and Development department of the local NHS trust who confirmed this was a service evaluation requiring local registration rather than ethical board review, in accordance with guidelines from the UK Health Research Authority. The project was therefore registered locally as a service evaluation project with reference Datix 5571. Interviewees were aware participation was voluntary, and agreed in writing to be audio recorded and for the potential publication of anonymized quotes. All data analysed and presented were anonymized at the point of transcription, and participants were assigned reference numbers to maintain confidentiality.
5 RESULTS
Eight MDT staff members across the ICU team described their experiences of the use of GBT in critical care. Half of the participants were therapy staff: (n = 4), two physiotherapists, one rehabilitation assistant, and one occupational therapy student, while the other half of the sample included nurses (n = 2), one nursing assistant and one medical consultant. Five staff participants were female, and the duration in the role ranged from 2 months to 13 years. Individual participant characteristics have not been presented here to ensure anonymity.
One overarching theme of humanizing health care was identified from the interviews, which described the impact of GBT on how staff perceived their interactions with patients. Three sub-themes were also identified: non-physical components of care; enhancing recovery; and bespoke tailoring. The reception of GBT and recommendations for change were also summarized to inform future service development.
5.1 Overarching theme: humanizing health care
I think they may realise as well that you are actually quite down to earth … not just nursing staff … we are people as well (S001, nurse assistant).
[Using GBT made the patient] feel a bit more human than a hospital number (S003, physiotherapist).
[GBT allows] your mind to shift for at least 15 minutes while you play so it's kind of like a break while you play (S005, nurse).
…it felt a bit inappropriate to my colleagues because let's say they are doing rolls [repositioning a patient in bed] … and I was playing ludo with the patient (S005, nurse).
…you might just have that one game that they play every Sunday at home (S002, rehabilitation assistant).
Hopefully it [GBT] will make their stay a little nicer (S003, physiotherapist).
It [GBT] gives a distraction, a more normalizing approach to a stay in somewhere that is [as] abnormal as ITU (S006, nurse).
I think it was also nice for them that they spend some quality time with the patient and do something different than just sit around the bedside (S005, nurse).
In this theme, the performance of GBT was identified as enhancing staff/patient relationships and supporting patients to be cared for as an individual. The provision of a distraction from such a difficult clinical setting was strongly valued, offering a means of normalizing the environment while enabling family members to contribute to their loved one's recovery.
5.2 Sub-theme: non-physical components of care
…promoting a day and night cycle for them is important… [to] reset the body clock (S002, physiotherapist).
The games are stuff they have grown up with … relatively straight forward things that they probably recognise from a long-term memory point of view (S008, medical consultant).
Staff generally placed strong emphasis on GBT as a positive adjunct to minimize the risks of non-physical morbidity through enhancing daytime stimulation and enabling re-orientation. This was described as enhancing non-physical recovery from critical illness alongside physical recovery.
5.3 Sub-theme: enhancing recovery
I think it prompts us to think a little bit more about other aspects of their mobility or rehab[ilitation] that we can challenge or look at (S007, nurse).
[GBT] adds a bit of interest and that makes it more stimulating for us (S007, nurse).
There was a perception amongst some staff members that GBT had the potential to be implemented as a strategy to focus on rehabilitation, and potentially accelerate recovery. It was suggested that if recovery could be optimized in critical care, this may aid patients to become more independent with self-care once transferred to the wards.27 This has potential benefits given the well-recognized impact of the change in patient to staff ratios on wards compared with ICU.28
In this service evaluation, staff described GBT as a positive adjunct to traditional care and therapies, optimizing recovery from critical illness, while encompassing therapeutic aims. It was suggested this may contribute to supporting restoration of independence and improving patient experience.
5.4 Sub-theme: bespoke tailoring
I had both extremes. People that didn't want to engage … [and] I've seen patients engage really well with it (S002, rehabilitation assistant).
…there is probably … the middle grey area… the ones that just ignore it… and ones that really enjoy it (S005, nurse).
We colloquially think of it as childhood but could be seen as a bit paternalistic… or patronising as you are now sitting and playing a kids' game (S008, medical consultant).
I think often their attitude to therapy we are offering in general, often, mirrors the engagement with games, so the patients that are generally reluctant to have nursing interventions, are refusing medications (S002, rehabilitation assistant).
I think storage of stuff is quite difficult as well. They cannot be [as] readily on display as you would want it to be (S005, nurse).
It was widely recognized that to be successful, GBT requires bespoke tailoring in terms of activity selection and therapeutic delivery. Interviewees emphasized not all patients will be willing to engage and benefit from this practice, and it may not suit everyone.
5.5 Recommendations for future development
As part of the aims of this service evaluation to explore implementation and support ongoing development, several recommendations for practice were also discussed. GBT was described as having been warmly adopted by the MDT across the ICU. In keeping with the introduction of a new tool, it has been steadily developed based on feedback from users.
Looking to future development opportunities, staff members recommended refining the selection of activities to suit a wider population. Some staff recommended exploring delivery with more independence for patients and within peer groups. In addition, staff recommended formalizing an educational package as part of promotion and delivery, to enhance staff understanding of the rationale and benefits of GBT. The overall consensus was positive, and several staff stated they hoped GBT would be adopted as a standard aspect of care rather than a supplementary adjunct.
6 DISCUSSION
This is the first study to our knowledge to explore the acceptability of GBT by the MDT for ICU patients. The overarching theme humanizing health care highlighted that despite the challenges of high acuity and pressurized nursing and therapist workloads in ICUs, GBT can facilitate individualized care and support development of strong rapport between patients and staff. Furthermore, during periods of frustration because of reduced autonomy associated with critical illness, GBT may offer some light relief and distraction for patients.
The first sub-theme identified GBT as supporting non-physical components of care with particular reference to optimizing cognitive re-orientation and day and night patterns. The implications of this on recovery were explored in the second sub-theme, enhancing recovery, identifying GBT as providing additional interventions beyond traditional nursing and therapist approaches to rehabilitation. The third sub-theme identified the need for bespoke tailoring whereby promotion, selection, and delivery of GBT need to be individualized. It was considered GBT would suit a proportion of the patient population but may not be for everyone.
Within the theme humanizing health care, developing strong rapport between staff and patients was identified as essential in promoting empathy and a sense of security for patients during periods of vulnerability and disability. This is pivotal as the culture of intensive care has shifted from merely ensuring survival to restoring quality of life.29 Beyond cognitive and physical recovery, patients should be empowered to restore their sense of identity.30 These findings are echoed by Kitwood's description of person-centred care in their work with patients with dementia.31 They state that principles of comfort, attachment, inclusion, occupation, and identity encompass the essence of care giving. In summary, humanizing health care signifies the importance of patient-centred care.
As part of non-physical components of care, MDT staff should undertake holistic assessments that detail physical and non-physical risks.32 Non-physical complications can vary in severity, but it is widely recognized that non-pharmacological management should be fundamental within the management package.33 GBT is a nice illustration of how non-pharmacological management can be utilized to aid re-orientation and aid cognitive stimulation.
Within the sub-theme enhancing recovery, some staff suggested GBT may contribute to accelerating physical recovery from critical illness, but this would need to be further investigated in future research, and was not examined in this service evaluation. Staff also spoke positively about how GBT promoted staff engagement with rehabilitation and enhanced staff/patient interactions. It is widely documented that the acuity and highly pressurized working environment of critical care can lead to emotional stresses, and risks staff burnout.34 The institutional environment is recognized as a component of Canadian Model Of Performance—Environment (CMOP) for patients35 but can be extended to staff too. Therefore, staff well-being and satisfaction are vital to foster to a cohesive workforce and minimize turnover, and promoting therapeutic relationships between staff and patients may contribute to this.36 If staff are invested in providing the best care and rehabilitation they can, it will contribute to supporting patients with their optimal recovery.
The importance of bespoke tailoring of activities was emphasized by several staff. While trying to individualize promotion and engagement with GBT, it may also be beneficial to revisit offering GBT throughout individual patients' critical care stay. As their health stabilizes, the principles of habituation and volitation from the Model of Human Occupation (MOHO) may change, and therefore their engagement might be enhanced.37 The MDT staff supporting GBT need to invest thought, even subconsciously, into establishing how best to understand what patients may be interested in and enjoy engaging with. Future development of GBT could explore the use of the MOHO Interest Checklists to support the MDT in tailoring GBT to individual patient needs. These are models of how individuals can generate and modify their occupations based on the environment and the desired action. Attention should be given to the time and use of interest checklists to establish which activities are best suited to individual patients. Consideration should be given to performance strategies such as supervised versus more independent activities, time of implementation, and enhanced education.
7 LIMITATIONS
There were limitations to this service evaluation. It was conducted at a single site in the United Kingdom with a relatively small sample size. Despite this, purposive sampling ensured representation of experiences from across the MDT. The sample size was considered appropriate for the aim of this service evaluation to assess local implementation of GBT. Furthermore, data collection ceased when the team agreed that data saturation had been reached, and no new codes were being generated. The research team intended to interview family members as well as staff, to understand their perceptions of GBT. However, several challenges, including the limited timeframe for data collection in the context of EK's secondment, the caseload of the ICU at the time, and difficulty in identifying family members willing to participate. Furthermore, a pragmatic decision was made during the design of this service evaluation not to interview patients about their experiences of GBT. Given the high acuity and prevalence of delirium in patients most commonly eligible for the intervention, it was anticipated that patients may not have been able or willing to recall their experiences within the limited timeframe of the project. However, the lack of patient and family member perspectives is a significant limitation to this work and should be addressed in future research where a wider timeframe may allow recruitment of patients at a point further into their recovery when they may be more able to engage in the research process. Finally, despite not being within the scope of this service evaluation, future research evaluating clinical benefits of GBT for recovery, impact on length of stay, and cost-effectiveness of GBT could be explored.
8 CONCLUSION
This qualitative service evaluation has demonstrated the implementation of a new GBT intervention as well received by staff in clinical practice. GBT was perceived by staff to encourage humanization of critically ill patients, and aid optimization of recovery. In the future, it may be beneficial to refine the activities with an emphasis on physical and non-physical therapy without losing the recreational aspects. Furthermore, thought should be given the delivery to maximize successful implementation and patient engagement.
ACKNOWLEDGEMENTS
With thanks to the MDT members of the Adult ICU who supported the implementation and service evaluation of GBT. Thanks also to the critical care research team at the Kadoorie Centre, University of Oxford who supported the development and analysis of this service evaluation.
