Australian Critical Care xxx (xxxx) xxx

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Research paper

Critically ill patients’ experiences of discomfort and comfort in theintensive care unit: A qualitative descriptive study
Yusuke Oyama, RN, PhD a, *, Hiroaki Yamase, RN, PhD b, Kyosuke Fujita, RN, BSN c,
Hiroshi Tashita, RN, MSN c, Tomoharu Honda, RN, MSN c, Koji Yoshida, RN, PhD a,
Akira Nagata, RN, PhD daNagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-shi, Nagasaki 852-8520, Japan; b Yamaguchi University
Department of Health Sciences, Graduate School of Medicine, 1-1-1 Minamikogushi, Ube-shi, Yamaguchi 755-8505, Japan; c Nagasaki University Hospital,
1-7-1 Sakamoto, Nagasaki-shi, Nagasaki 852-8520, Japan; d Ehime University Graduate School of Medicine Nursing and Health Science Course, 454
Shitsukawa, Toon-shi, Ehime 791-0295, Japan

article informationa b s t r a c t

Article history:
Received 21 April 2024
Received in revised form
5 August 2024
Accepted 29 August 2024

Background: The physiological state of critically ill patients is severely impaired by illness or trauma andis uncomfortable. Such experiences cause long-term anxiety and post-traumatic stress disorder.
Objective: This study aimed to understand discomfort and comfort based on the experiences of criticallyill adult patients in the intensive care unit and to explore ways to improve their comfort.
Methods: This qualitative descriptive study was conducted with 15 critically ill patients (age range: 46
e81 years; six females) in the intensive care unit using semistructured interviews and participant
observation. The data collected were analysed using Braun and Clarke's thematic analysis. Data werecollected from the intensive care unit and general ward of a university hospital in Japan.
Findings: Six themes related to discomfort and comfort were identiﬁed. The three themes related to
discomfort were “overlapping uncertainties”, “being unable to control physical discomfort”, and “having
to endure psychologically and situationally”. The three themes related to comfort were “feeling connected brings calm”, “routine care relieves pain and thirst”, and “ease when one can decide for oneself”.
Participants’ discomfort involved physical and psychological factors and was related to treatments,
procedures, care, and the environment. Moreover, more than half of the patients endured unmet needs.
Comfort was brought about by providing routine care for physical discomforts that critically ill patients
often experience, feeling alive and connected to others and encouraging independence.
Conclusion: Recognising the potential for physical and psychological discomfort, as well as communication and other difﬁculties, in critically ill patients is crucial. Patients may also experience discomfort
when healthcare providers take the lead, which underscores the importance of involving patients in theircare. By showing respect for patients’ intentions and involving them in decision-making, healthcare
providers can improve patient comfort and promote a more collaborative approach to care.
© 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. This is an open accessarticle under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Keywords:
Critical care
Critically ill
Discomfort
Patient comfort
Qualitative research
Qualitative descriptive study

1. Introduction
1.1. Meaning of comfort in critical care
Providing comfort is a central goal in nursing. Comfort is theimmediate experience of strength when one's needs for relief, ease,and transcendence are met in four contexts (physical, psychospiritual, social, and environmental).1 In contrast, discomfort is an* Corresponding author at: 1-7-1 Sakamoto, Nagasaki-shi, Nagasaki 852-8520,
Japan.
E-mail address: osuke@nagasaki-u.ac.jp (Y. Oyama).

unpleasant feeling or sensation or a negative state, and one's natural response to it is to avoid or reduce it via actions or verbal or
nonverbal behavioural cues.2 Based on the patient's response,
practitioners must focus not only on treating discomfort
symptoms but also on providing comfort.3
However, in critical care, comfort needs are complex. The
physiological state of critically ill patients is severely impaired byillness or trauma and is markedly uncomfortable. Physically, theyexperience discomforts such as pain,3 dyspnoea,4 and thirst.5e7
Psychologically, they are prone to feelings of helplessness andvulnerability due to their inability to communicate and the lack ofa sense of control.3,8 Such experiences can not only reduce theirhttps://doi.org/10.1016/j.aucc.2024.08.011
1036-7314/© 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/
licenses/by/4.0/).

Please cite this article as: Oyama Y et al., Critically ill patients’ experiences of discomfort and comfort in the intensive care unit: A qualitativedescriptive study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2024.08.011

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comfort but also cause long-term anxiety and post-traumaticstress disorder.9
In addition, the implications of the intensive care unit (ICU)
environment and the presence of healthcare professionals must be
considered to improve their comfort. Olausson et al.10 describedcomfort from theoretical and empirical perspectives, focussing on
the ICU environment, as related to feeling close to nature, individuals' intentions, past experiences, understanding the situation, and being able to move without strain. Synonyms for comfort
were also indicated, such as satisfaction, calm, relaxation, release,peacefulness, and strengthening. Focussing not only on the patient's illness or injury but also on discomfort symptoms caused by
the ICU-speciﬁc environment is necessary to improve comfort.
Hojjatoleslami et al.11 identiﬁed the theme of the “nurse's healing
presence” and showed that it is a crucial factor in all aspects ofcomplex and critical illness and hospitalisation situations for patient comfort, with immediate and long-term positive outcomes.

1.2. Comfort needs and care perspectives in critical care
In order to provide comfort care, it is necessary to understandhow patients perceive discomfort and comfort. Several metasyntheses have explored discomfort and comfort based on the experiences of ventilated patients. Carruthers et al.12 described how
enduring uncomfortable medical procedures, such as ventilation,
endotracheal suctioning, injections, and position changes, exhaustpatients mentally and physically and how health professionals'
personalised care and trust positively inﬂuence patients' experiences. Danielis et al.13 found four themes in their metasynthesis:“the effect of intense stress on the body's systems”, “the induced
negative emotional situations”, “the feeling of being cared for in a
hospital setting”, and “perceived support from family and loved
ones”. Moreover, “feeling comforted” was a frequent code acrossstudies. In both studies, an important resource for patients' physicaland psychological discomfort was the presence and care ofhealthcare professionals. Wensley et al.14 explored the perspectivesof patients undergoing heart surgery regarding comfort in acutecare. They found that understanding the patients' needs during
their interactions with healthcare staff is important for improving
their comfort. Berntzen et al.15 indicated that a gap exists between
the comfort needs of ICU patients and nurses' achievements in
fulﬁlling them and that discomfort is an inevitable part of thecritical illness trajectory. Thus, although healthcare professionals'
care improved patient comfort, there were unmet medical needs
and discomfort. This ﬁnding implies a lack of comfort care for
critically ill patients. Comfort is an essential component of care andshould be assessed from patients' perspectives.1 This highlights theneed for an in-depth exploration of patient experiences, explicitly
focussing on discomfort and comfort.
Many studies describing the experiences of critically ill patients
have been conducted in Europe and the United States, particularlyin the Scandinavian countries. Because culture, ethnicity, andenvironment inﬂuence comfort, such studies must be conducted indifferent areas of the healthcare environment. It is imperative tolisten to patients’ experiences globally, and further research isneeded.13 A local understanding of cultural changes and the mosteffective interventions for transferring knowledge is crucial forevidence-based medicine.16 Therefore, studies should be conductedin clinical settings in which critically ill patients receive care.
In stressful healthcare situations, where comfort needs are high,
the goal is to provide enhanced comfort compared to the previous
baseline.1 Effective comfort care must be provided by understanding both discomfort and comfort among critically ill patients.
Therefore, this study aimed to understand discomfort and comfort

based on the experiences of critically ill adult patients in the ICU
and to identify ways to increase their comfort.
2. Methods
2.1. Design
We performed a qualitative descriptive study to comprehensively explore participants’ experiences in plain language.17
2.2. Setting
Data were collected in the ICU and general ward of an 800-bed
university hospital in a rural city in Japan. The ICU had 20 beds, ofwhich two were private and the others were public. Sixty nurses
worked in the ICU, where data were collected. Two of them had
master's degrees, and three were certiﬁed nurses in critical care by
the Japanese Nurses Association. Each nurse was responsible for
one to two patients and worked two shifts: one during the day andthe other at night. During data collection, although the impact of
the coronavirus disease 2019 (COVID-19) was waning, most visitswere restricted.
2.3. Participants
The participants were adult patients in the ICU for more than
12 h. They were selected using purposive sampling.18 The ﬁrst
author asked adult patients in the emergency department or cardiac surgery unit who were scheduled to be admitted to the ICU toparticipate in the study in a face-to-face setting. Fifteen patientsagreed to participate, whereas ﬁve declined. The participants had
never met the interviewer. Patients who were awake, could remainaware of the situation, and could speak and understand Japanese
were included in the study.
No participants were sedated when interviewed. Additional
interviews were conducted with most participants 3 to 8 days after
ICU discharge. Unable to schedule an interview with them, one
participant (Patient 9) could not be interviewed post ICU discharge.
The average age of the participants was 65.3 years (range: 46e81
years), and most were male (60.0%). All participants had cardiovascular diseases, and 14 had undergone surgery.
2.4. Data collection
Data were collected from May to September 2022 throughsemistructured interviews19 and participant observations.20 The
level of participation in the observation was "observer as participant". The ﬁrst author conducted semistructured interviews one tofour times per participant in the general ward and at the ICU
bedside. These interviews were conducted in the absence of nonparticipants and were recorded on a digital voice recorder withparticipants' consent. Prior permission was obtained from the ICU
clinician and the attending physician for the ﬁrst author to conduct
participant observation in the ICU. Participant observations wereconducted before and after the interviews in the ICU. Participants'
words, facial expressions, and behaviour were recorded in the ﬁeld
notes during vital sign measurements, mobilisation, bed bathing,and procedures, as well as in the ICU environment. To preserve thepatient's experience, brief ﬁeld notes were taken in the clinicalsetting and elaborated immediately after leaving the ICU. Data
collection was concluded upon obtaining duplicate data.
Data on participants' characteristics (age, sex, diagnosis at thetime of admission, surgery, duration of mechanical ventilation, andduration of ICU stay) were collected from electronic medical records according to their face sheet (Table 1). The interview guidePlease cite this article as: Oyama Y et al., Critically ill patients’ experiences of discomfort and comfort in the intensive care unit: A qualitativedescriptive study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2024.08.011

Y. Oyama et al. / Australian Critical Care xxx (xxxx) xxx

3

Table 1
Participant characteristics.
Patient number

Age

Sex

Admission diagnosis

Durationof MV (hours)

Durationof ICU
stay (hours)

Number ofinterviews

Duration ofinterviews in the
ICU (minutes)

Duration ofinterviewsin generalward (minutes)

1
2
3
4
5
6
7
8
9
10
11

64
48
74
66
57
70
62
70
81
62
80

M
F
F
M
F
M
M
M
F
M
M

0
2.5
22
113.5
4
13
4
0
3
0
0

41
17
41.5
280
18
64.5
65
19.5
19.5
16.5
16.5

2
2
2
2
2
3
3
2
1
2
2

20
11
15
25
21
15
28
18
12
18
15

42
25
22
44
26
48
23
41
0
29
31

12
13

46
70

M
F

2.5
68.5

20.0
185

2
4

8
43

50
27

14
15

76
53
Range
(mean)
46e81(65.3)F
M

Acute aortic dissection Stanford B
Pulmonary stenosis
Thoracic aortic aneurysm
Angina pectoris
Mitral insufﬁciency
Thoracic aortic aneurysm
Aortic stenosis
Abdominal aortic aneurysm
Aortic stenosis
Abdominal aortic aneurysm
Acute thromboembolic
lower limb arterial occlusion
Hypertrophic cardiomyopathy
Tricuspid regurgitation,
Mitral insufﬁciency
Thoracic aortic aneurysm
Chronic aortic dissection

17
13.5
Range (mean)
0e113.5 (17.6)

65.0
87.0
Range (mean)
16.5e280 (63.7)

2
2

21
2
Range (mean)
2e43 (18.1)

1427
Range (mean)
0e50 (29.9)

Note: M: male; F: female; MV: mechanical ventilation; ICU: intensive care unit.

consisted of open-ended questions based on a literature review14,21,22 and the authors' experiences in the ICU. The sample
questions were as follows: What were your experiences in the ICU?
Have you ever felt comfortable in the ICU? Have you ever felt uncomfortable in the ICU? What were the causes of your comfort anddiscomfort? The questions were tailored to ﬁt the participant's
narrative to elicit their feelings and thoughts.
2.5. The stance of the researchers
The ﬁrst author had 15 years of clinical experience as a registered male nurse and had worked in emergency rooms and ICUs.
The ﬁrst author was a university researcher and was not involvedin the treatment or care of patients in the ICU of the hospitalwhere the participants were admitted. All research members had
extensive clinical experience in intensive care, and four were
afﬁliated with universities and had experience in qualitative
studies.
2.6. Data analysis
The data collected from semistructured interviews and participant observations were uploaded to NVivo Windows (QSR International) and analysed using thematic analysis.23 Table 2 lists thesix steps of data analysis.
2.7. Rigour
Rigour was ensured as follows. Raw data and codes wereshared with all researchers and discussed to build consensus andunderstanding and to make modiﬁcations. Participants' check was
performed with one participant. We checked with the participant
whether the interpreted results reﬂected patients’ comfort anddiscomfort in the ICU. Although the analysis was led by the ﬁrst
author, a qualitative researcher supervised the analysis process. To
ensure trustworthiness, repeated meetings with ICU nurses were
held to share ﬁndings and conﬁrm the accuracy of the data
analysis.

Dependability, credibility, and conﬁrmability were also considered during this process. To ensure transferability, the themes were
described in detail by citing participants’ narratives.24

2.8. Ethical considerations
This study was conducted in accordance with the Declarationof Helsinki.25 Owing to concerns about the risk of coercing patients to participate in the study, the study was explained by theﬁrst author, who was not involved in the treatment or care ofpatients in the ICU. The participants were informed that they
could withdraw from the study at any time. They were also
explained that if the interview became distressing, it would be
discontinued. Verbal and written informed consent was obtained
from all the participants. In the ICU, the participants were contacted after conﬁrming with the in-charge nurse that their condition was stable. Participants’ consent was reconﬁrmed during
the interview and participation observation. No payments weremade to the participants. The recorded interviews were anonymised during transcription. The study protocol was approved by
the Nagasaki University Hospital clinical research ethics committee (approval number: 22041819).

3. Findings
From the data collected, 823 codes were extracted describing
discomfort and comfort in the ICU. These codes were categorised
based on their patterns, similarities, and differences. The categorised codes were named based on their characteristics, and 17
subthemes were identiﬁed. Out of six themes, three themes related
to discomfort, including “overlapping uncertainties”, “being unable
to control physical discomfort”, and “having to endure psychologically and situationally”, and three themes related to comfort,
including “feeling connected brings calm”, “routine care relieves
pain and thirst”, and “ease when one can decide for oneself”, wereobtained based on the patterns in the subthemes, as shown in
Table 3.

Please cite this article as: Oyama Y et al., Critically ill patients’ experiences of discomfort and comfort in the intensive care unit: A qualitativedescriptive study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2024.08.011

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Y. Oyama et al. / Australian Critical Care xxx (xxxx) xxx

After a detailed description of the themes and subthemes,
relevant interview (e.g., Patient 1) and ﬁeld note (e.g., Field note 1)
data were presented as examples.

Table 2Six steps of thematic analysis (Braun and Clarke, 2006).
Thematic analysis
1

2

3

4

5

6

Familiarising oneself with the data
The authors repeatedly reviewed the content of the interviews and ﬁeld
notes to check the accuracy of the transcriptions and made corrections if
required. The content of the verbatim transcripts was read repeatedly
to grasp the overall meaning, and initial ideas were noted.
Generating initial codes
The verbatim transcripts were re-read line by line and coded intomeaningful units concerning patients' comfort and discomfort experiences.
Searching for themes
The codes were categorised into potential themes based on theirpatterns and similarities.
Reviewing the themes
The potential themes were reviewed to ensure that they reﬂected themeaning of the extracted codes and the overall data set.
Deﬁning and naming the themes
We determined the aspects of the data captured by each theme.
Themes and subthemes were identiﬁed through a detailed analysis andreﬁnement of the individual themes and data.
Producing the report

3.1. Discomfort among critically ill patients in the ICU
Participants’ discomfort involved physical and psychologicalfactors and was related to treatments, procedures, care, and theenvironment. Three themes related to discomfort are described in
the following.
3.1.1. Overlapping uncertainties
In the ICU, the participants were uncertain about their surroundings, including the time, place, physical condition, and thefuture.
3.1.1.1. Being confused due to delusion and realistic dreams.
Several participants experienced delusion and were unsure
whether it was real or a dream. The patients described this as a
dream-like, fearful experience they distinctly remembered, even

Table 3
Themes and subthemes of discomfort and comfort in the ICU.

Discomfort

Theme

Subtheme

Researchers' ﬁeld notes and participants' quotations

Overlapping uncertainties

Being confused due to delusion
and realistic dreams
Being unable to understand
one's surroundings andcondition
Experiencing pain

I thought I was being controlled by machines attached to myhands and neck. (Patient 1)
There is nothing to do but look at the ceiling. Sometimes, I justlook to the right or left. (Patient 4)

Being unable to control physicaldiscomfort

Experiencing severe thirst

Having to endure
psychologically andsituationally

Not seeing improvements inphysical condition
Not being able to move one's
body as desired
Not being able to ﬁnd the callbuttonNot being able to speak

Wanting to cause as little
trouble as possible
Obey with unchangeable
situations in health care

ComfortFeeling connected brings calm

Routine care relieves pain andthirstEase when one can decide foroneself

Talking to a friendly healthcare
professional provided relief

Feeling relieved after surviving
Feeling reassured because of
the presence of family
Relief with analgesics andposition changes
Quenching thirst with water

Wanting to do things oneself
Glad to have someone dosomething one cannot do

After all, pain comes ﬁrst. It is still a struggle against pain.
(Patient 12)
I don’t feel anything without food. It's just that I’m thirsty.
(Patient 4)
I had arrhythmia and palpitations and couldn’t sleep for about 2days because of it. (Patient 2)
I think the most painful thing is not being able to move my bodythe way I want to. (Patient 3)
When the patient scratched his head with his left hand and let
go of the call button, he lost track of where the button was andgroped for it. (Field note 9)
I had no way of communicating when phlegm was stuck, sowhen someone passed by my bed, I asked them to take a tissue
by gesturing with my hand. (Patient 10)
I wanted to cause as little trouble as possible. (Patient 11)
The nurse lowered the bed without explaining it to the patient.
The patient looked a little surprised but said nothing. (Field note
6)
It's medical care, so I don't think I have a choice anymore.
(Patient 8)
I am still concerned about what will happen, so I am relieved
when a medical professional explains to me ”This is roughly
what will happen”. (Patient 7)
I think my symptoms improved a lot because I talked to them;
they listened to me, and they were sincere. (Patient 10)
When I woke up, I thought oh, I'm alive, I'm okay. (Patient 5)
It is a relief to see my children. (Patient 11)
It was a pain, but they give you painkillers right away… That
was a great help. (Patient 15)
The patient holds a glass of water in his hand and gargles threetimes. His thirst is reduced, and his facial expression becomes
calm. (Field note 10)
I want to do what I can, even if it's slowly, without always
having to depend on medical professionals. (Patient 3)
I know I'm asking a lot, but I can't move on my own, so it wasrefreshing to have my body washed. (Patient 4)

ICU: intensive care unit.

Please cite this article as: Oyama Y et al., Critically ill patients’ experiences of discomfort and comfort in the intensive care unit: A qualitativedescriptive study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2024.08.011

Y. Oyama et al. / Australian Critical Care xxx (xxxx) xxx

after leaving the ICU. One participant said that he felt as if thestretcher on which he was lying was moving. He told some nurses
about it, but they did not believe him.
“I don’t think the stretcher’s brakes were on. The stretcher was
moving backwards, little by little, bit by bit. When I told the nurses,
they didn’t believe me” (Patient 4).
One participant repeatedly recounted his experience of having acentral venous catheter or arterial line inserted and said that it
controlled his body. They also talked about how they were aware of
their own death in the space between reality and dreams. Sometimes, they joined their hands and prayed to their ancestors. Beingaware of this possibility was terrifying, and some patients had tears
in their eyes when they talked about it.
“I was worried. I thought I was no longer in this world” (Patient 4).
3.1.1.2. Being unable to understand one's surroundings and condition.
When participants woke up and realised they were in the ICU, they
were unaware of their physical condition. One participant also
shared that when he was in the bed, he could only see the ceiling;
there were calendars and clocks hanging on the walls of the ICU, but
he could not notice them. Even if he had noticed them, he said he
could not see them clearly. Participants struggled to get a sense of
the day and time.

5

3.1.2.4. Not being able to move one's body as desired. The participants talked about the pain caused by their inability to move theirbodies. They described feeling as if their immobile body did notbelong to them. They also felt frustrated by their inability to do theirown thing.
“It feels like someone else’s body, not my own” (Patient 4).
3.1.3. Having to endure psychologically and situationallyThe participants endured difﬁculties ﬁnding the call button,
being unable to speak, and wanting to cause as little trouble aspossible. In addition, they experienced surprise, depression, andembarrassment about the medical environment and sudden medical treatment. The circumstances surrounding the participants,
such as emergency surgeries, urgent procedures, defecation care,
the ICU environment, and restricted visits, caused them discomfort.
3.1.3.1. Not being able to ﬁnd the call button. The participants talked
about looking for the call button, not being able to ﬁnd it, and not
being able to call the nurse.
“I was choking on phlegm and wanted to call (a nurse) to suction it
out. I was looking for the call button, but couldn’t ﬁnd it” (Patient
8).

“My head is fuzzy, my body doesn’t move, and I don’t know whatstate I’m in” (Patient 5).
The patient spends most of his time in a supine position. He
often looks at the ceiling and does not move (Field note 1).

3.1.3.2. Not being able to speak. Patients with artiﬁcial airways
sometimes had to wait because they could not speak andcommunicate their intentions.

“There was a clock over there (right wall), but I was blind and didn’tknow what time it was” (Patient 2).

“If I can get the words out, I tell the nurse, but if I try to communicate with gestures, the nurse does not understand” (Patient 6).

3.1.2. Being unable to control physical discomfort
All participants experienced pain, and more than half had a dry
mouth. Other physical discomforts were uncontrollable dyspnoea,
palpitations, nausea, and fatigue. The inability to move one's bodyto deal with these discomforts was also painful.

3.1.3.3. Wanting to cause as little trouble as possible. The patientswanted to cause as little trouble as possible for the healthcare
personnel, so they looked for the right time to call for help.

3.1.2.1. Experiencing pain. The participants experienced postoperative wound pain, pain associated with the disease, pain fromprocedures, and movement-induced wound pain. They were also
defensive against pain.

“I tried to ﬁgure out how much I could endure it. I thought I would
call a nurse if I couldn't endure it” (Patient 5).

3.1.2.2. Experiencing severe thirst. The participants experienced
severe thirst and stated that discomfort was beyond anything they
could imagine.

3.1.3.4. Obey with unchangeable situations in health care. Twoparticipants had to undergo emergency surgery. One wasdepressed by the sudden event but said that he had no choice but toleave it to the doctors. Participants also expressed surprise atsudden X-rays, and other examinations and procedures, resistanceto having nurses take care of their defecation, and the restrictions of
the ICU environment (restricted visits, beds, lighting, noise, and soon) were unavoidable for the treatment.

“I’m already thirsty. It’s like you want a drink every time” (Patient
8).

“The doctors were like, let’s remove the tubes today. I was like,‘What?’” (Patient 2)“After drinking water, pain appeared in the chest area, and it took
2e3 minutes to calm down” (Patient 14).

3.1.2.3. Not seeing improvements in physical condition. Various
discomforts were not controlled. The participants talked about how
the moving parts of their bodies distracted them from thediscomfort. The researchers observed many behaviours, such as
participants rubbing their chests and gripping bed fences. The
participants experienced distress and a sense of nowhere to belong.
The patient complained of fatigue, repeatedly grabbing the bed
rails with her hands, rubbing her chest area, and exhibiting
other behaviours (Field note 3).

(To be taken care of in defecation) “There was some resistance.
There was resistance, but I had no choice” (Patient 1).

3.2. Comfort among critically ill patients in the ICU
The participants described comfort using words such as ”calm”,”ease”, ”overcome”, ”pleasant”, ”improve”, ”glad”, ”relieve”,”wonderful”, and ”revive”. Three themes related to comfort aredescribed in the following.

Please cite this article as: Oyama Y et al., Critically ill patients’ experiences of discomfort and comfort in the intensive care unit: A qualitativedescriptive study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2024.08.011

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Y. Oyama et al. / Australian Critical Care xxx (xxxx) xxx

3.2.1. Feeling connected brings calm
Feeling connected to the outside world and other people wasimportant for improving participants' comfort. The participants
could feel alive and calm down by communicating with healthcare
professionals, asking about their condition, feeling the passage oftime, and receiving encouragement from family members. Someparticipants sensed the passage of time and perceived the situation
based on their room's brightness or changes in healthcare professionals. However, for most participants, receiving informationfrom their healthcare professionals was helpful.
3.2.1.1. Talking to a friendly healthcare professional provided relief.
The participants talked about how the healthcare professionals
explained to them individually what was happening, what toexpect, and how they were praised for early mobilisation. The
participants who thought that they would not be able to get out of
bed the day after surgery could do so with the help of their physicaltherapist and nurses. They felt reassured and calm as they could
understand the situation because of the healthcare professionals.
They talked pleasantly about the friendliness and attentiveness ofthe healthcare professionals.

“I never thought it would be so hard not being able to drink water
until now. Even just wetting my mouth revived me” (Patient 2).
3.2.3. Ease when one can decide for oneself
Being able to decide for themselves made the participants feel
relaxed, calm, and pleased.
3.2.3.1. Wanting to do things oneself. The participants said that it
was important to be able to make their own decisions and do it on
their own, even if it took time.
“When you have a choice, you feel more relaxed, like choosing
something easier for today or trying a little harder” (Patient 15).

3.2.3.2. Glad to have someone do something one cannot do.
The participants felt relieved when they decided to leave what they
could not do to the healthcare professionals.
“A physical therapist came and helped me sit up. So, I felt refreshedagain. It felt good, or rather, I felt like I could entrust my body to him
with peace of mind” (Patient 14).

“Words are always nice to hear. When I am praised for doing
something that I thought I would never be able to do because it
would be too tiring, it makes me feel good” (Patient 7).

4. Discussion“They listen to the smallest complaint and think, ‘What can I do toﬁx this?’ I think that this surpasses even excellent medical care”(Patient 10).

This study aimed to understand discomfort and comfort basedon the experience of critically ill adult patients in the ICU and to
identify ways to improve their comfort. Consequently, six themes
were identiﬁed: three related each to discomfort and comfort.

3.2.1.2. Feeling relieved after surviving. The participants talked
about their relief at being alive when they woke up after surgery
and how they felt as if they had overcome their difﬁculties whenthe morning sun brightened their hospital room.
“I was relieved to ﬁnd out that it was the morning. Ah, a day had
passed. Ah, I had overcome (another day)” (Patient 5).
3.2.1.3. Feeling reassured because of the presence of family.
The participants talked about being reassured by the presence offamily members over the phone or during visits. Remembering
encouraging words from family members motivated the participants to do their best.
“My brothers and son came, and it gave me relief. He left, saying,‘Hang in there’” (Patient 11).
3.2.2. Routine care relieves pain and thirst
The participants described how pain and thirst were relieved by
the routine care provided by nurses.
3.2.2.1. Relief with analgesics and position changes. Most participants received pharmacological interventions, such as opioid
therapy and/or intravenous acetaminophen, prophylactically and/or according to patient complaints. They also stated that they were
subjected to repeated positional changes. They said that thesepharmacological and nonpharmacological interventions relieved
their pain.
“I had my body turned around repeatedly, and it helped” (Patient2).
“If I got sore, they put me on a drip for pain relief, and it went away”(Patient 9).
3.2.2.2. Quenching thirst with water. The participants’ verbal andfacial expressions showed how their thirst was alleviated by water.

4.1. Characteristics of discomfort among critically ill patients
This study revealed that discomfort arose from uncertainty, pain,
thirst, the ICU environment, and the inability to communicate one's
needs or move one's body, including communication with healthcare professionals. These ﬁndings are similar to those found in the
study by Ashkenazy et al.,4 who found unmet patient needs to be thefundamental trigger of discomfort in the ICU. However, Ashkenazy
et al.4 excluded confused patients from their study; therefore, patients who reported suffering from delusion as part of psychologicaldiscomfort were not included. Delusion was associated with unrealistic experiences and awareness of the possibility of death. The
descriptions of discomfort were associated with real events, whichis consistent with the study by Berntzen et al.,3 who reported thatthey were accompanied by both factual and delusional memories.
The participants described actual physical discomfort as delusions,which were related to life-threatening fears. Such delusion and fearin the ICU are associated with long-term cognitive decline and posttraumatic stress disorder.26,27 Healthcare professionals must
recognise that discomfort in the ICU has long-term effects.
Eight participants reported that they had endured unmet needs.
This may have contributed to their discomfort. Berntzen et al.3
reported that patients expressed the necessity of endurance andendured pain and other discomforts. Similarly, in this study, theparticipants endured various discomforts in addition to pain. Evenin severe situations, they attempted to be considerate of healthcare
professionals and other patients as they felt that they were not the
only ones suffering. It should be emphasised that critically ill patients should not endure discomfort.
Participants' endurance was also related to communication.
Studies have reported that the inability to communicate effectively
leads to fear, helplessness, loneliness, and decreased
independence.3,4,9,28,29 This study revealed that the inability toutter words prevented one from communicating one's intentions.
Additionally, being unable to ﬁnd the call button forced participants

Please cite this article as: Oyama Y et al., Critically ill patients’ experiences of discomfort and comfort in the intensive care unit: A qualitativedescriptive study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2024.08.011

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to wait patiently without a way to complain of discomfort. Thissituation was contrary to feeling ”reassured by having my call bell
nearby”, which Tolotti et al. found.29 We believe that this suggests aneed for improved communication strategies in the ICU. Communication is a salient part of care, and nurses must be alert and adjust
their communication strategies to patients' needs and communication abilities.30 In addition, there were situations where participants accepted and endured the healthcare and ICU environment,
including treatments, examinations, and care, believing they had
no choice. In critical illness, the patient's voice is weak and almost
unheard, making the patient compliant with caring actions.31
Healthcare professionals must understand the vulnerability ofthese critically ill patients.
Furthermore, patients' facial expressions and behaviours when
they experience discomfort must be noticed as these aspects may
reveal the type of discomfort they are experiencing. One participant
repeatedly rubbed their chest, gripped the bedrail with a distorted
expression on their face, and appeared restless. They described thisas fatigue. The Critical Care Pain Observation Tool and Behavioral
Pain Scale are pain-rating scales that determine pain levels basedon body movements.32,33 However, it is important to recognise thatpatients’ behaviours do not always reveal their pain.
4.2. Characteristics of comfort among critically ill patients
The comfort experiences found in this study are similar to thosefound in other studies involving ICU patients and may contribute tostrengthening the literature in this ﬁeld.
Participants experienced improved comfort from receiving information about their physical condition and what to expect. They
felt their bodies recovered and overcame the obstacles by listening
to the words of healthcare professionals and by feeling alive. This issimilar to the transcendence that Kolcaba described.1 We foundthat even though the patient experienced some discomfort, they
were motivated by words and found satisfaction in having a senseof recovery. In addition, the healthcare professionals' kindness andsincerity improved patients' comfort. Baumgarten and Poulsen28
have reported that a clear and sincere presence of nurses is
crucial to the patient's experience and helps alleviate their vulnerabilities, such as anxiety, fear, and loneliness. Furthermore, patients felt more comfortable when nurses spoke pleasant words in apleasant tone and tried to cooperate with them on common issues
with kindness, goodness, and respect.12 Among healthcare professionals, nurses are always approximate to their patients, andtheir attitude towards patients is essential for patients' comfort.
These caring attitudes are also important to promote patients'
wellbeing and satisfaction with their care.31 Timely and appropriate
intervention was found to be important as routine care alleviatedphysical discomforts such as pain and thirst. The participants reported that analgesic administration was particularly effective forpain. Acetaminophen was prescribed as an adjunct to opioids forpatients after cardiac surgery and could be administered according
to patient complaints. The pain, agitation or sedation, delirium,
immobility, and sleep guidelines suggest that ICU patients experience pain daily, even at rest, and that pain assessment and analgesia before the procedures are important.34 In the ICU where theparticipants were admitted, patient pain was assessed using thenumeric rating scale and the Critical Care Pain Observation Tool,32
awareness was assessed using the Richmond AgitationeSedation
Scale,35 and delirium was assessed using the confusion assessment method for the ICU.36 The ability to administer analgesics
according to patients' perception of pain effectively relieved pain.
We identiﬁed situations in which pharmacological interventions alleviated pain in ICU patients. However, other discomforts must also be addressed, as Berntzen et al.3 described the7pain as being relieved, but patients still struggled. The theory of
unpleasant symptoms describes how the exact factors may inﬂuence one's experience of various symptoms, and consequently,
similar interventions may be effective in alleviating more than one
symptom.37 This may also be applied for discomfort and comfort
among critically ill patients. When using the taxonomic structure of
comfort theory, it is important to consider all known discomforts
and risk factors and that comfort obtained in one context will always affect comfort in other contexts.1 Furthermore, patients' responses to care should be carefully monitored as healthcare
professionals' care may improve comfort but may also cause
discomfort.
Critically ill patients depend on others and lack a sense of control.4,9 However, they recalled feeling signiﬁcant relief when theirneeds were met, and they did not feel helpless.9 In this study, it was
important for patients to ask for care on their own, leaving what
they could not do themselves in the hands of the nurses. Patients’recognition and expression of their needs, even if dependent, givethem autonomy and bring comfort.38
5. Limitations
This study involved talking to patients at their bedside, where
they receive treatment and care, and observing them during theirillness, providing realistic insight into patients' situations andincreasing the credibility of this study. However, this study hassome limitations. First, the number of patients was limited tothose with cardiovascular diseases. However, as cardiovasculardiseases account for more than 30% of deaths worldwide andrequire continuous monitoring and intensive care,39,40 this study
may have effectively described the experience of critically ill patients. Second, because the interviews were conducted in the ICU,
delusion and other psychiatric symptoms may have affected their
quality. However, we supplemented the data by interviewing
patients again after their discharge from the ICU. Third, owing to
COVID-19, ICU visits were restricted. This may have affected patients’ comfort.
6. Conclusions
This study explored patient care by focussing on the experience of critically ill patients in the ICU from both comfort anddiscomfort perspectives. Critically ill patients experienced various
physical and psychological discomforts in the ICU, leading tocommunication problems, such as the loss of the call button andthe inability to speak. In addition to the discomfort caused by theunique ICU environment, patients also experienced discomfort insituations where they were dependent, and therefore, thehealthcare provider took the lead, regardless of the patients' intentions. This underlines the importance of involving patients intheir care. By showing respect for patients’ intentions andinvolving them in decision-making, healthcare providers canimprove patient comfort and promote a more collaborative
approach to care.
Furthermore, the patients’ experiences of comfort and discomfort in this study provide perspective to examine the impact onrecovery after ICU discharge and complications such as mental andcognitive disorders.
Funding
This work was funded by the Japan Society for the Promotion of
Science, Tokyo, Japan (JSPS KAKENHI) grant numbers: JP 20K10786,
23K09981).

Please cite this article as: Oyama Y et al., Critically ill patients’ experiences of discomfort and comfort in the intensive care unit: A qualitativedescriptive study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2024.08.011

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Y. Oyama et al. / Australian Critical Care xxx (xxxx) xxx

CRediT authorship contribution statement
Yusuke Oyama: conceptualisation, methodology, formal analysis,
investigation, resources, data curation, writingdoriginal draft, writingdreview and editing, project administration, Funding acquisition. Hiroaki Yamase: conceptualisation, methodology, formal
analysis, data curation, writingdreview and editing, project
administration, Funding acquisition. Kyosuke Fujita: methodology,
formal analysis, investigation, resources, data curation, writingdreview and editing. Hiroshi Tashita: methodology, formal
analysis, investigation, resources, data curation, writingdreview andediting. Tomoharu Honda: methodology, formal analysis, data
curation, writingdreview and editing. Koji Yoshida: methodology,
formal analysis, data curation, writingdreview and editing. Akira
Nagata: conceptualisation, methodology, formal analysis, investigation, resources, data curation, writingdreview and editing, project
administration, Funding acquisition.
Conﬂict of interest
The authors declare that they have no known competing
ﬁnancial interests or personal relationships that could haveappeared to inﬂuence the work reported in this manuscript.
Data availability statement
Due to the nature of this study, the participants did not agree for
their data to be shared publicly. Thus, supporting data are notavailable.
Acknowledgements
We are grateful to all study participants for their cooperation.
We want to thank Editage (www.editage.com) for the Englishlanguage editing.
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