
==== Front
Heliyon
Heliyon
Heliyon
2405-8440
Elsevier

S2405-8440(24)12542-X
10.1016/j.heliyon.2024.e36511
e36511
Research Article
Interpretative structural modeling method: An analysis of influencing factors analysis on the adverse experiences of cardiac surgery patients in the intensive care units
Wang Yan 1134994192@qq.com
⁎1
Yu Yun 1
Xu Tingting 1
Wang Zheyun
Fang Yating
Nanjing Drum Tower Hospital The Affiliated Hospital to Nanjing University Medicine School, 210008, Nanjing, China
⁎ Corresponding author. Cardiothoracic Surgery Intensive Care Unit, No.321 Zhongshan Road, Gulou District, Nanjing, Jiangsu, China. 1134994192@qq.com
1 Yan Wang,Yun Yu and Tingting Xu contribute equally.

22 8 2024
15 9 2024
22 8 2024
10 17 e3651111 10 2023
16 8 2024
16 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Objective

To construct an interpretation structure model of adverse experiences of cardiac surgery patients in intensive care unit, so as to provide a reference for optimizing the experience of critical patients step by step.

Methods

Literature review, semi-structured interviews, questionnaires and Delphi method were used to summarize and analyze the influencing factors of intensive care experience in cardiac surgery. The explanatory structural model was used to divide the influencing factors into levels and construct the explanatory structural model of adverse experience of cardiac surgery patients in intensive care.

Results

A hierarchical structure model containing 34 elements and 15 levels was constructed, which were divided into Surface level, middle level and root level.

Conclusion

The intensive care experience of patients in cardiac surgery department is mainly affected by 34 factors. There are direct or indirect correlations between the influencing factors, and different levels have different effects.

Keywords

Interpretative structural modeling method
Bad experience
Cardiac surgery
Intensive care unit
==== Body
pmcWith continuous improvements in economic, educational, and medical technology, there is a growing demand for health among people. Furthermore, as medical disciplines become more refined, an increasing number of specialties are establishing independent Intensive Care Units (ICUs) to offer specialized treatment and care for critically ill patients. The increasing number of patients require admission to ICUs due to sudden illnesses, perioperative monitoring, and other factors. Although the primary objective of the ICU is to enhance survival rates, the patient experience is frequently neglected, both by the general public and healthcare providers, potentially heightening the risk of anxiety, depression, or delirium, consequently influencing outcomes [1,2]. The intensive care experience of ICU patients mainly comes from five aspects: memory, cognition, sensation, information, and environment [3], and adverse experiences often make patients feel " fear", "being monitored", "nightmares, hallucinations", etc [4,5]. After discharge from the ICU, some patients continue to be troubled by issues such as post traumatic stress disorder (PTSD) and post-intensive care syndrome (PICS) [6,7]. As the survival rate of ICU patients continues to improve [8,9], there is increasing scholarly attention towards the patient experience during ICU stays. The experience of critically ill patients has become a key indicator of ICU nursing quality [10]. Identifying and optimizing the ICU patient experience is crucial for enhancing the physical and mental well-being, as well as the overall quality of life, of ICU patients. Numerous factors in clinical practice may impact the experience of ICU patients. Relevant studies have analyzed the causes of patients' adverse experiences during ICU and tried to construct assessment tools and scales [11]. However, the correlation and hierarchical logic between the factors contributing to ICU patients' adverse experiences remain unclear. On the basis of literature retrieval, qualitative interviews and Delphi method, this study hierarchically divided the influencing factors of adverse experience of cardiac surgery patients in ICU with the help of the explanatory structure model in modern systems engineering, so as to provide a reference for optimizing the experience of cardiac surgery ICU patients step by step.

1 Materials and methods

1.1 Composition of members

The team comprised 4 senior, 3 intermediate, and 3 junior medical staff. All had over 5 years of ICU experience, including 1 head nurse from the general ward of cardiac surgery department, 1 head nurse from the cardiac surgery ICU, and 1 cardiac surgery ICU director, each possessing extensive clinical management expertise. The ICU head nurse is a pivotal member of our hospital's nursing psychological support group, possessing solid theoretical knowledge and practical experience in psychological nursing. The remaining staff have extensive experience in nursing critically ill patients.

1.2 Data sources

1.2.1 Literature retrieval method

Through literature review and discussion by team members, the problem of this literature search was determined to be the adverse experience or experience of patients after cardiac surgery during ICU monitoring. The search terms were "Cardiac Surgical Procedures/Cardiac Surgery" "Patient/Sufferer" "ICU/Intensive Care Units/Department of Intensive Medicine" "Bad Experience/Negative Experience". The search time limit was from the establishment of the database to March 31, 2022. The database includes: PubMed, Cochrane Library, BMJ Best Practice, Joanna Briggs Institute (JBI), Scottish Intercollegiate Guidelines Network (SIGN), National Institute for Health and Care Excellence (NICE), National Guideline Clearinghouse (NGC), Web of Science, Dutch Medical Abstracts database, SinoMed, CKNI, Wan Fang database, VIP database, Medical Pulse Guide network. The inclusion criteria were: ①Chinese or English literature; ②age ≥18 years old; ③The target population was inpatients. Exclusion criteria: ①The full text could not be obtained; ②The patient stayed in ICU for less than 24 h. Through combing and summarizing the collected literature, the influencing factors of adverse experience of cardiac surgery patients in intensive care unit were preliminarily summarized.

1.2.2 Semi-structured interview method

Drawing upon the findings from the literature review and integrating the research objectives, expert consultations were conducted to develop an initial interview outline. Pre-interviews were conducted face-to-face with two patients undergoing cardiac surgery undergoing cardiopulmonary bypass under general anesthesia, who remained in the cardiac surgical care unit for over 24 h and subsequently transferred back to the general ward post-recovery. The final interview outline was developed based on the interview results, which were subsequently refined as outlined below: (1)Were you dissatisfied during your ICU stay? (2)Which aspects of the ICU experience led to your dissatisfaction? (3) What aspects of your ICU stay were most difficult to understand? (4)What were your most urgent needs during your ICU stay? (5)What was the most painful aspect of your ICU experience? (6)From your perspective, what improvements could be made in the ICU? The objective of this study is to further understand and summarize the factors influencing the adverse experiences of patients in the cardiac surgery intensive care unit, as derived from the interview results. This study received approval from our hospital's Ethics Committee, with the approval number 2023-089-02. Subsequently, sufficient semi-structured interviews were performed a cohort of 20 patients who were admitted to the cardiac surgery intensive care unit and successfully transferred to the general ward. The interviews were conducted at the bedside in the general ward. Prior to the interviews, patients were fully informed about the purpose and content of the study, and written informed consent was obtained from all subjects. The NVivo 11 qualitative analysis software was utilized to analyze and refine the influencing factors. Following focus group discussions, similar factors were consolidated. Additionally, insights from the actual work of frontline clinical staff were integrated to supplement the medical care and management factors.

1.3 Research methods

1.3.1 Focus group discussion method

Conduct small group discussions. Influencing factors identified from literature review and semi-structured interviews were discussed and revised to establish the initial influencing factors associated with adverse patient experiences in cardiac surgery.

1.3.2 Questionnaire survey method

The initial influencing factors were made into a questionnaire, and Likert 5-point scoring method was used to calculate 1–5 points from "no impact" to "very impact". Higher scores indicated greater importance of the influencing factors. The questionnaire was pushed to medical staff engaged in cardiac surgery care by wechat in the form of WenJuanXing, and the importance of each factor was scored, so as to identify the main factors of adverse experience of cardiac surgery patients in intensive care.

1.3.3 Delphi method

Ten medical and nursing experts related to cardiac surgery intensive care were selected, including experts engaged in cardiac surgery intensive care research, cardiac surgery intensive care nursing experts, cardiac surgery nursing managers, and psychological researchers engaged in critical patients. Through two rounds of written letter consultation, experts were invited to evaluate the main factors and decide whether to retain them. Combined with the experts' modification suggestions, the key factors affecting the intensive care experience of cardiac surgery patients were determined. Through the form of expert scoring, the relationship between each pair of influencing factors was determined, and the adjacency matrix of influencing factor relationship was established.

1.3.4 Explain the structural model

Interpretative Structural Modeling Method (ISM) is a widely used analytical method in modern systems engineering, classified as one of the structural modeling techniques. It can transform vague thoughts and views into intuitive models with good structural relations, and has a wide range of applications. It is especially suitable for system analysis with many variables, complex relations and unclear structure, and can also be used for scheme ranking. It is used in the medical industry for hospital management [12] and system building [13] to help hospital administrators better make decisions and analyze risk factors. The steps of constructing the explanatory structural model of this study included: Identifying the influencing factors of adverse experiences in the cardiac surgery intensive care unit; Establishing the adjacency matrix; Calculating the reachability matrix; Performing hierarchical division; Constructing the explanatory structural model.

1.3.5 Statistical methods

The NVivo 11 qualitative software was utilized to organize and analyze the interview data. Other qualitative data were converted to quantitative data and analyzed by SPSS 22.0 software. The count data were represented in terms of frequency and percentage, whereas the measurement data were depicted as either the mean (χ‾±S) or the median. The Chi-square (χ2) test was applied to analyze differences in gender and length of service. Age data were subjected to a one-way analysis of variance (ANOVA). The scores of influencing factors were evaluated using a non-parametric test.

1.3.6 Study time node

Literature search and group discussions were conducted from March 2022 to August 2022. Ethical approval processes took place from March 2023 to April 2023. Semi-structured interviews were conducted between April 2023 and June 2023. Questionnaires were collected in July 2023, followed by model construction from August 2023 to September 2023.

2 Results

2.1 Determination of influencing factors of adverse experience in cardiac surgery patients in intensive care unit

2.1.1 Preliminary identification of influencing factors based on literature retrieval and semi-structured interviews

By reviewing the relevant literature, in order to ensure the number of literature, on the basis of combining with clinical practice, the literature related to the adverse experience of non-cardiac surgery patients in intensive care was included in the search process, such as ICU mechanical ventilation patients, ICU physical restraint patients, and so on. A total of 22 relevant literatures were screened. Taking environmental factors as an example, "light stimulation" [14], "instrument alarm" [15] or "temperature" [16] in the literature can be summarized as environmental factors. Following the focus group discussion, a total of 77 initial influencing factors were ultimately included, as shown in Table 1.Table 1 Initial factors of adverse intensive care experience in cardiac surgery patients.

Table 1Classification of factors	Influencing factors	Number of factors	
Patient Factors	thirst, pain, nausea, vomiting, sore throat, dizziness, chest tightness, limb swelling, sleep disorders, limb numbness, loss of appetite, expectoration weakness, back and neck pain, restlessness, delirium	15	
Factors of health care workers	medical rounds, health status of doctors and nurses, personal mood of doctors and nurses, personal character of doctors and nurses, psychological quality of doctors and nurses, technical level of doctors and nurses, family situation of doctors and nurses, ability of doctors and nurses, risk awareness of doctors and nurses, sense of responsibility and empathy of doctors and nurses, relationship between doctors and nurses, working atmosphere	12	
Factors of treatment	physical cooling, mechanical ventilation, sputum suction, vascular puncture, thoracentesis, protective restraint, excessive cable, limited activity, indwelling catheter, wound drainage, chest strap, health education	12	
Factors of management	energy level matching, physician-nurse rotation, nurse-patient relationship model, nurse-patient communication style, diet not timely, incidence of equipment failure, difficulty of equipment use, performance distribution, training assessment, human resources, morning study, continuous working hours, nursing document writing, work intensity	14	
Environmental factors	temperature, humidity, light stimulation, instrument alarm, personnel speech, bed density, bed turnover, excreta odor, goods placement, lighting equipment	10	
Psychological factors	illness worry, financial worry, fear, powerlessness, lack of security, lack of interpersonal needs, lack of privacy, boredom, loneliness	9	
Other Factors	defecation and urination in bed, receiving new surgical patients, sudden rescue, outcome of other patients, quality of bed unit	5	
Total initial factors	77	

2.1.2 Determination of main influencing factors based on questionnaire survey

A total of 105 questionnaires were distributed to hospitals with cardiac surgery and intensive care units, and 105 questionnaires were returned, with a recovery rate of 100 %. There were 13 invalid questionnaires and 92 valid questionnaires, with an effective rate of 87.6 %. A total of 4 Grade A tertiary hospitals were included in the valid questionnaires, and the numbers were H1, H2, H3 and H4. There were no statistically significant differences in gender, age, working hours and ICU working hours of medical staff among the hospitals; general information is shown in Table 2. Nonparametric test was used to test whether there were statistical differences in the importance scores of the initial influencing factors among different hospitals, and the results of rank sum test are shown in Table 3. According to the results of rank sum test, the average score of the main influencing factors was calculated, and the average score of more than 3 points was taken as the main influencing factors, a total of 49 factors. The results of the main influencing factors are shown in Table 4.Table 2 General information of the questionnaire on factors of adverse experience in intensive care for adult cardiac surgical patients.

Table 2Project	H1(n = 10)	H2(n = 50)	H3(n = 21)	H4(n = 11)	Test statistic values	P value	
Gender (example, %)					2.8381)	0.389	
Male	2(20.00)	4(8.00)	4(19.05)	1(9.09)			
Female	8(80.00)	46(92.00)	17(80.95)	10(90.91)			
Age(χ‾ ±s)	32.20 ± 4.39	31.08 ± 5.34	30.38 ± 4.06	33.00 ± 6.80	0.7452)	0.528	
Length of hospital work experience (example, %)					4.4631)	0.213	
Less than 5 years	2(20.00)	14(28.00)	6(28.57)	0(0)			
More than 5 years	8(80.00)	36(72.00)	15(71.43)	11(100.00)			
Working years in ICU (example, %)					4.4631)	0.213	
Less than 5 years	2(20.00)	20(40.00)	9(42.86)	3(27.27)			
More than 5 years	8(80.00)	30(60.00)	12(57.14)	8(72.73)			
1 Fisher's exact test.

2 One-way ANOVA.

Table 3 Rank sum test of initial influencing factors scores of different hospitals (Kruskal-Wallis H test).

Table 3Initial influencing factors	Z value	P value	Initial influencing factors	Z value	P value	Initial influencing factors	Z value	P value	
thirst	2.089	0.554	chest strap	8.861	<0.05	bed density	0.941	0.816	
pain	1.978	0.577	admission of new surgical patients	1.53	0.675	worry about illness	2.622	0.454	
nausea	2.911	0.406	emergency rescue	2.178	0.536	economic worries	4.776	0.189	
vomiting	0.826	0.843	outcomes of other patients	0.588	0.899	fear	2.73	0.435	
sore throat	0.535	0.911	medical rounds	2.508	0.474	sense of powerlessness	5.098	0.165	
dizziness	2.462	0.482	temperature	2.594	0.459	lack of security	4.71	0.194	
chest distress	2.572	0.462	humidity	5.896	0.117	insufficient interpersonal needs	3.871	0.276	
limb swelling	3.715	0.294	light stimulation	5.393	0.145	lack of privacy	1.696	0.638	
sleep disorders	0.626	0.89	alarm of instrument	4.518	0.211	boredom	0.402	0.94	
numbness of the limbs	2.559	0.465	speech by personnel	3.659	0.301	loneliness	9.319	<0.05	
loss of appetite	2.022	0.568	quality of sheet element	4.371	0.224	bed turnover	1.791	0.617	
asthenia of sputum production	2.815	0.421	too many cables	9.671	<0.05	rotation of care	4.352	0.226	
back and neck pain	1.68	0.641	limitation of movement	6.566	0.087	energy level matching	2.987	0.394	
physical cooling	0.162	0.984	an indwelling catheter was placed	0.329	0.954	nurse-patient relationship model	0.454	0.929	
mechanical ventilation	0.84	0.84	drainage of wound	1.025	0.795	nurse-patient communication style	0.36	0.948	
suction of sputum	1.171	0.76	pee and defecate in bed	2.349	0.503	thoracentesis	2.72	0.437	
vascular puncture	1.31	0.727	not eating in time	4.609	0.203	constraint of protection	0.886	0.829	
delirium	3.834	0.28	agitation	3.381	0.337				

Table 4 Main influencing factors of adverse experience of intensive care in cardiac surgery patients.

Table 4Classification of factors	Main influencing factors	Number of factors	
Psychological factors	illness worries, financial worries, sleep disorders	3	
Patient Factors	limitation of activity, weakness, expectoration weakness, thirst, pain, sore throat, back and neck pain, dizziness, chest tightness, vomiting, nausea, loneliness, lack of interpersonal needs, lack of privacy, lack of security, fear, delirium, restlessness, defecation in bed, limb swelling, limb numbness	21	
Factors of treatment	sputum aspiration, vascular puncture, thoracentesis, excessive cable, indwelling catheter, wound drainage, mechanical ventilation, protective restraint, emergency rescue	9	
Factors of health care workers	personal character of doctors and nurses, psychological quality of doctors and nurses, sense of responsibility and empathy of doctors and nurses, personal mood of doctors and nurses, technical level of doctors and nurses, their own ability, risk awareness of doctors and nurses, health status of doctors and nurses, relationship between doctors and nurses, working atmosphere	10	
Factors of management	work intensity, continuous working hours, equipment failure rate, equipment use difficulty, instrument alarm, human resources	6	
Total number of main influencing factors	49	

The calculation method of the average score of the main influencing factors is as follows.

If there was no significant difference in the importance score of the influencing factor, the average score = the total score of the factor/92; Otherwise, the average score within each hospital was calculated first, and then the average score = (χ‾ H1+ χ‾ H2+ χ‾ H3+ χ‾ H4)/4.

2.1.3 Determination of key influencing factors based on Delphi method

According to the revised opinions of experts, nausea and vomiting were summarized as gastrointestinal discomfort, sputum aspiration, vascular puncture and thoracentesis were summarized as invasive procedures, etc. The defecation and excessive cable on the bed were modified to the difficulty of toileting, and the pipeline cable was disorderly. Finally, 34 key factors F affecting the intensive care experience of patients in cardiac surgery were identified, which were F1-F34, as detailed in Table 5.Table 5 Key influencing factors of poor experience in intensive care for patients in cardiac surgery department.

Table 5Classification of factors	Key Influencing Factors	Number of factors	
Psychological factors	F1 disease worries, F2 economic worries, F3 sleep disorders	3	
Patient Factors	F4 decreased self-care ability, F5 thirst, F6 pain, F7 dizziness, F8 chest tightness, F9 gastrointestinal discomfort, F10 lack of interpersonal support, F11 lack of privacy, F12 lack of security, F13 fear, F14 delirium restlessness, F15 difficulty in toileting, F16 limb swelling and numbness	13	
Factors of treatment	F17 invasive operation, F18 pipeline cable messy, F19 drainage tube placement, F20 mechanical ventilation, F21 protective restraint, F34 sudden rescue	6	
Factors of health care workers	F22 personal character of doctors and nurses, F23 psychological quality of doctors and nurses, F24 sense of responsibility and empathy of doctors and nurses, F25 personal emotion of doctors and nurses, F26 working ability of doctors and nurses, F27 health status of doctors and nurses, F28 clinical work atmosphere	7	
Factors of management	F29 clinical work intensity, F30 equipment failure rate, F31 equipment use difficulty, F32 instrument alarm, F33 human resources	5	
Total number of Key Influencing Factors	34	

2.2 Construction of explanatory structural model for influencing factors of adverse experience in intensive care

2.2.1 Establish the adjacency matrix

A matrix questionnaire was made of 34 key factors affecting the intensive care experience of patients in cardiac surgery, and the experts were visited to judge the relationship between the two factors. The adjacency matrix A=(aij)N × N is constructed, where N = 34, so as to determine the adjacency matrix A of the key influencing factors, see Figure A in the attachment for details.aij={1，FihasadirecteffectonFj0，FihasnodirecteffectonFj

2.2.2 Calculating the reachability matrix

By adding the adjacency matrix to the identity matrix I, that is, by adding A to I, A new matrix A1=(A + I) is obtained. If the element aij in A1 is 1, it means that it can be directly reached from node to node. If A1 is not a reachable matrix, it should be calculated according to the need. By taking A1 squared, that is, A12=(A + I)2 = A2+A + I, and use the Boolean algebra rule for operation, the rule is 0 + 0 = 0, 0 + 1 = 1, 1 + 1 = 1; 0 × 0 = 0, 1 × 0 = 0, 1 × 1 = 1, and then the reachability matrix R of the influencing factors of adverse experience in intensive care for cardiac surgery patients was obtained, as shown in Figure B in the attachment.

2.3 Performing hierarchical division

Based on the reachable matrix R, the reachable set S(Fi) and the antecedence set Q(Fi) are identified, and then the intersection W(Fi) of them is determined, that is, W(Fi) = S(Fi)∩Q(Fi). According to the relationship between the reachable set S(Fi) and the intersection W(Fi), 15 levels were finally identified.

2.3.1 Constructing the explanatory structure model

According to the hierarchy of influencing factors, the multi-level explanatory structure model of the influencing factors of adverse experience of cardiac surgery patients in intensive care was drawn, which was divided into 15 hierarchical structures, including the surface layer (influencing factors of the thirteenth to fifteenth layer), the middle layer (influencing factors of the fourth to twelfth layer), and the root layer(influencing factors of the first to third layer), as shown in Fig. 1 for details.Fig. 1 Explanatory structural model of influencing factors of poor experience in intensive care for cardiac surgical patients.

Fig. 1

2.4 Effects of different working years on the scores of key influencing factors

There were statistical differences in the scores of key influencing factors due to different working years of medical staff. Among them, there were statistical differences in the scores of a total of 13 key influencing factors when the medical staff had different working years in hospitals. When the working years in ICU are different, the scores of a total of 7 key influencing factors are statistically different. The longer the working years in ICU are, the higher the scores of key influencing factors are, as shown in Table 6.Table 6 Comparison of the scores of key influencing factors by different working years.

Table 6Different length of hospital service	Different length of ICU service	
Key factors	Initial influencing factors	Z value	P value	Key factors	Initial influencing factors	Z value	P value	
Invasive Procedures	Suction of sputum	−2.932	0.003	Invasive Procedures	Suction of sputum	−1.979	0.048	
Vascular puncture	−2.869	0.004	Vascular puncture	−2.423	0.015	
Pleural puncture	−2.62	0.009	Pleural puncture	−2.478	0.013	
Drainage tube placement	An indwelling catheter was placed	−2.343	0.019	Drainage tube placement	An indwelling catheter was placed	−2.273	0.023	
Drainage of wound	−2.616	0.009	Drainage of wound	−2.588	0.01	
Alarm of instrument		−2.929	0.003	Alarm of instrument		−2.555	0.011	
pipeline cable messy		−2.092	0.036	pipeline cable messy		−2.022	0.043	
fear		−3.726	<0.001	fear		−2.499	0.012	
Decreased self-care ability	Sense of powerlessness	−2.683	0.007	Emergency rescue		−2.015	0.044	
Limitation of movement	−2.132	0.033	Protective constraint		−2.331	0.02	
Insufficient interpersonal needs		−2.449	0.014					
Lack of privacy		−2.744	0.006					
Delirium agitation	Agitation	−2.816	0.005					
Delirium	−2.278	0.023					
Mechanical ventilation		−2.3	0.021					
Lack of security		−2.952	0.003					
Worry about illness		−2.269	0.023					
Economic worries		−2.015	0.044					

3 Discussion

3.1 Interpretation structural model analysis of adverse experience of cardiac surgery patients in intensive care

3.1.1 Root factors are the crux of patients' adverse experience

F22, F24, F26, F30, and F31 have a fundamental impact on ICU patients' experience. From the explanatory structural model (Fig. 1), it can be seen that the personal personality of doctors and nurses is at the bottom of the model. Personal character affects the sense of responsibility and empathy of medical staff. On the one hand, the sense of responsibility will drive medical staff to continuously improve their working ability, on the other hand, empathy will make medical staff more willing to understand the physical and mental feelings of patients. The improvement of working ability can reduce the physical pain of patients, and better empathy ability can relieve the psychological burden of patients. This is particularly important for patients in the ICU. The difficulty of using the equipment also affects the working ability of medical staff from the side. At the same time, the occurrence of equipment failure causes frequent alarms of the instrument, which makes patients lack of security and ultimately leads to patients experiencing adverse experiences. It can be seen that a positive personal character is the basis and prerequisite for medical staff to work, and medical equipment with stable performance and easy operation is the guarantee to improve the working ability of medical staff. However, due to the concealment of the root factors, this link is often overlooked by medical managers.

3.1.2 Middle-level factors are the visual embodiment of patients' adverse experience

Thirst, pain, fear and so on are the visual manifestations of the adverse experience of patients in cardiac surgical intensive care unit. Patients are unable to eat or exercise normally due to mechanical ventilation, gastrointestinal discomfort and other reasons. The disturbance of water and electrolyte, pain stimulation and the reversal of day and night caused the patients to have sleep disorders. The emergency rescue made the patients worry about their own condition and economy. Long-term physical pain and psychological suffering increase the risk of delirium in patients, and the application of protective restraints further reduces the self-care ability of patients, which aggravates the numbness and discomfort of patients and the workload of clinical medical staff. This link can intuitively feel the increase in patient demand, and the work problems and pressure faced by medical staff increase accordingly. It is necessary to strengthen the control of this link and take corresponding intervention measures.

3.1.3 Surface layer factors are the final expression of patients' adverse experience

In this study, the adverse experience of cardiac surgery patients in intensive care was finally manifested in three aspects: lack of privacy, physical discomfort and lack of interpersonal support, which were related to patients' long time in bed and repeated changes in condition. Due to the need of treatment, such as indwelling catheterization, thoracentesis, etc., patients cannot adequately protect their privacy. Due to the concern of their own condition, ICU patients need strong interpersonal support to enhance their confidence in healing. However, due to the work intensity of medical staff, personal emotional changes and human resources and other factors, it is often difficult for medical staff to provide adequate psychological comfort for patients. The particularity of ICU greatly limits the companionship of patients' family members, resulting in the lack of family support for patients. Therefore, patients often seek family support for the first time after their condition is stable and they are transferred out of the intensive care unit, which is consistent with Maslow's hierarchy of needs theory. In this process, patients will talk to their families about their adverse experiences during ICU. Although this is a necessary process for patients to go through during ICU, some patients and their families will choose to complain to the third party to eliminate their dissatisfaction. In the long run, the resistance of patients and their families to ICU is increasing, and the medical staff will be confused because of the incomprehension of patients and their families, resulting in job burnout and even resignation.

3.2 The degree of attention to intensive care experience of cardiac surgery patients with different working years is different

With the increase of working years, the attention of medical staff to the ICU experience of cardiac surgery patients also increased. Consistent with the study by Yuan Mei et al. [17], nurses with higher working years paid more attention to the impact of instrument alarm. For the medical staff with lower working years, they need to devote more energy to observe the vital signs of ICU patients, so they have no time to pay attention to the physical discomfort caused by the pipeline cable. The interesting phenomenon in this study is that the medical staff who have been working in hospitals for more than 5 years seem to pay more attention to the psychological activities of patients, such as disease worry, lack of security and lack of privacy; While the medical staff who had worked in ICU for more than 5 years paid more attention to the adverse experience of patients brought by sudden rescue and protective restraint. This may be related to their work experience. Medical staff who have been working in hospitals for more than 5 years have more opportunities to contact patients and their families in general wards due to early standardized training and department rotation, so as to better understand the needs and ideas of patients. The medical staff who had worked in ICU for more than 5 years lacked communication with patients and their families due to fixed posts and occupational specificity, and paid more attention to the negative impact of medical behavior. Therefore, for medical staff who have been working in ICU for a long time, regular general ward rotation may be able to relieve work pressure and improve the empathy ability of ICU medical staff.

4 Suggestions

4.1 Optimize the job allocation system and on-the-job empathy training for employees based on the professional personality test

With the reform of the medical model, the cultivation of professional ability of medical staff has changed to psychological, safety and other aspects of quality training. Based on the professional personality test, the implementation of individualized management strategies is conducive to improving the job satisfaction of medical staff [18]. On the one hand, hospitals can add personality tests in the recruitment process, so as to coordinate the positions of new employees. On the other hand, with the increase of working years, medical staff will inevitably experience job burnout and compassion fatigue, which needs to be improved from many aspects such as salary and welfare, work pressure and theme training [19], so as to improve the professional identity and empathy ability of medical staff.

4.2 Simplify the human-computer interaction of medical equipment and improve the work efficiency of medical staff

ICU medical staff need to master a series of high-precision life support instruments. Complex operation interface, multi-brand models and non-native language keys will increase the difficulty of medical staff to use. At the same time, with the gradual popularization of hospital information technology, more and more clinical medical links need to use computers, tablets and other terminals for operation, and the frequency of human-computer interaction has increased significantly. Therefore, in the process of equipment procurement and information system development, the research of clinical first-line medical staff should be strengthened. Clinical tests and feedback optimization should be carried out repeatedly before the product is put into use, and more clinical time should be left to patients by simplifying the human-computer interaction.

4.3 Accelerate the renewal of clinical medical concept and strengthen the intervention of adverse experience of ICU patients

Through theoretical training, scenario simulation and other methods, the cognitive degree of ICU medical staff on adverse experience was improved, so that they were aware of the negative impact brought by adverse experience. Combined with the latest guidelines, expert consensus and clinical practice, the medical and nursing standards suitable for our specialty are formulated, so as to shorten the time of mechanical ventilation, reduce pulmonary complications, relieve wound pain, etc., so as to promote the early rehabilitation of patients, reduce the burden of clinical work, and improve the satisfaction of patients and their families.

4.4 Implement the rotation system of ICU medical staff and promote the dynamic adjustment of human resources

The fixed post work system is still the current clinical mainstream. Its advantage lies in that with the increase of working years, the specialized ability of medical staff tends to be stable, and it is also conducive to department management and performance distribution. For ICU medical staff, long-term high-intensity work is not good for physical and mental health. Once a public health emergency occurs, intensive care personnel are relatively scarce. The implementation of ICU medical staff rotation system, on the one hand, can relieve the pressure of ICU work, ICU medical staff can have more opportunities to witness the recovery and discharge of patients, enhance the sense of professional achievement and identity, on the other hand, in the process of rotation, other specialized medical staff can receive intensive care training, can reserve more intensive care talents in case of emergency. Therefore, it is necessary to further explore the department management and performance distribution scheme during the rotation of ICU medical staff.

5 Summary

Based on the explanatory structure model, this study conducted a hierarchical analysis on the influencing factors of adverse experience of cardiac surgery patients in intensive care, so as to understand the process of patients experiencing adverse experience more intuitively. We divided the layer into three layers: the Surface layer, the middle layer and the root layer, and discussed the problems combined with clinical practice. On this basis, we discussed the improvement plan. However, due to the small number of Grade A tertiary hospitals that can carry out cardiac surgery, the number of questionnaire respondents is relatively insufficient, and the interview for cardiac surgery patients is also limited by regions. Therefore, the population included in this study has certain regional characteristics, and multi-center studies are still needed to verify.

For ethics approval

This study was reviewed and approved by Medical Ethics Committee of Nanjing Drum Tower Hospital with the approval number: 2023-089-02, dated: 2023-04-11.

Data availability statement

The original interview data used in this article could not be made public because the ethics committee of our hospital did not approve the disclosure of relevant patient data.

The original results of the questionnaire used in this article are publicly available and can be accessed at: https://www.wjx.cn/report/230041309.aspx.

CRediT authorship contribution statement

Yan Wang: Writing – original draft, Resources, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Yun Yu: Writing – original draft, Resources, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Tingting Xu: Writing – original draft, Resources, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Zheyun Wang: Writing – review & editing, Writing – original draft, Supervision, Project administration, Methodology, Conceptualization. Yating Fang: Investigation, Data curation.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Attachments

Fig. A Adjacency matrix A of influencing factors of adverse experience in intensive care for patients undergoing cardiac surgery.

Fig. A

Fig. B Reachability matrix R of influencing factors of adverse experience in intensive care for cardiac surgery patients.

Fig. B

Appendix A Supplementary data

The following is the Supplementary data to this article:Multimedia component 1

Multimedia component 1

Acknowledgements and Funding

The authors would like to acknowledge that this research work was partially financed by 10.13039/501100019155 Nanjing Drum Tower Hospital from the research grant number: NDYG2022073 .

The funding was funded by two projects, namely.

1. Project of Chinese Hospital Reform and Development Institute, Nanjing University.

2. Aid project of Nanjing Drum Tower Hospital Health, Education & Research Foundation.

We would like to thank Zhu Chengyin, Yang Zhiyun, Ge Min, Chen Cheng, Su Yunyan, Jin Hua, Xie Xiaoli, Hu Yuexiu and Guan Yan for their active participation in the group discussion and providing meaningful reference comments.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.heliyon.2024.e36511.
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