Occupations, freedom, and values: a case study in a Coronary Intensive Care Unit

Abstract

Introduction

Illness can be a limiting factor for engaging in occupations, especially when the person hospitalized in an Intensive Care Unit (ICU). The ICU environment, which is associated with a rigid routine and invasive procedures, can have various repercussions for the hospitalized individual. In this study, the perspective on the individual is based on Viktor Frankl’s Logotherapy and Existential Analysis, which views humans in their entirety and as capable of enduring suffering and finding meaning in life through the realization of values.

Objective

Understand how occupations are experienced by individuals in a Coronary ICU and address them considering freedom and values.

Method

This is a qualitative, exploratory, descriptive case study. Data were collected through a semi-structured interview and a free expression activity.

Results

It was observed that the ICU routine impacts occupations, as does the loss of autonomy and independence and the manifestation of feelings of fear, anxiety, and social isolation. Nevertheless, considering the human dimension of noetic freedom, the participant responded to these challenges by realizing creative, experiential, and attitudinal values.

Conclusion

The way hospitalization in an ICU impacts occupations can be modified if the individual adopts an alternative attitude towards the given conditions. In this context, engaging in occupations can enable the realization of values, which facilitates finding a new meaning of life.

Keywords:
Activities of Daily Living; Logotherapy; Hospitalization; Occupational Therapy

Resumo

Introdução

O adoecimento pode ser um fator limitante para a realização das ocupações, principalmente quando se está internado em uma Unidade de Terapia Intensiva (UTI). O ambiente da UTI, que está associado à rotina rígida e procedimentos invasivos, pode trazer diferentes repercussões à pessoa internada. Nesta pesquisa, considerou-se a visão sobre a pessoa com base na Logoterapia e Análise Existencial de Viktor Frankl, que compreende o ser humano em sua totalidade e como capaz de suportar o sofrimento e encontrar o sentido da vida por meio da realização de valores.

Objetivo

Compreender como se apresentam as ocupações para a pessoa internada em uma UTI Coronariana e abordá-las considerando a liberdade e os valores.

Método

Pesquisa qualitativa, exploratória, descritiva, do tipo estudo de caso. Os dados foram coletados por meio de uma entrevista semiestruturada e uma atividade de expressão livre.

Resultados

Observou-se que a rotina da UTI impacta as ocupações, assim como a ocorrência de perda da autonomia e independência e a manifestação de sentimentos de medo, ansiedade e isolamento social. Apesar disso, considerando a liberdade do ser humano que remete a dimensão noética, a participante se posicionou mediante as dificuldades realizando valores criativos, vivenciais e atitudinais.

Conclusão

A forma como a internação em UTI impacta as ocupações pode ser modificada se a pessoa assumir uma atitude alternativa diante das condições dadas. Nesse contexto, o envolvimento em ocupações pode possibilitar a realização de valores, o que favorece o encontro de um novo sentido da vida.

Palavras-chave:
Atividades Cotidianas; Logoterapia; Hospitalização; Terapia Ocupacional

Introduction

The process of becoming ill can be characterized as an undesirable state and a limiting factor for the performance of occupations, such as instrumental activities of daily living (IADL), work, leisure, social participation, and, depending on the severity of the illness, even of simpler tasks such as activities of daily living (ADL) (Pinto & Paiva, 2021; American Occupational Therapy Association, 2020).

When illness destabilizes biological systems, causing changes that require life support interventions, intensive care unit (ICU) admission is necessary. The ICU is associated with rigid and inflexible routines. It is an environment filled with equipment, discomfort, impersonality, lack of privacy, dependence on technology, social isolation, and the risk of imminent death (Gomes & Carvalho, 2018).

In circumstances of ICU admission, occupations like bathing are sometimes performed in bed; functional mobility—walking, sitting, and transferring—are only performed together with the rehabilitation team; and other occupations, such as work and leisure, cannot be conducted. Because of the clinical condition and/or ICU routine, people suffer loss of function and engagement in their significant occupations (Hammill et al., 2019).

Being hospitalized can arouse feelings of fear and anxiety given the severity of the illness, invasive procedures, social distancing, as well as death. It can be considered a significant threat to an individual’s life, leading to physical, emotional (Membrive et al., 2017), social (Gabarra et al., 2020), occupational (Maia et al., 2020), and spiritual (Elmescany & Barros, 2015) repercussions, in addition to impairments in autonomy and independence (Monteiro et al., 2017).

In this context, it should be considered that illness and ICU admission can disrupt the performance of occupations (Neves et al., 2018). The study by Almeida et al. (2017), titled “On the Occupations of Elderly People in Hospital Conditions: What is their Form and Meaning?”, highlights that when a person is hospitalized, they may assume a passive and little or non-participatory condition from an occupational perspective.

Occupations can be defined as personalized and meaningful involvement in daily activities by a particular person, performed in different contexts, which are influenced by performance patterns and competencies, as well as by environmental and client factors (American Occupational Therapy Association, 2020).

To promote occupations, occupational therapists seek to identify—based on the occupational routine before hospitalization—a particular activity of interest to be adapted and performed in the hospital setting that can assist the person in coping with the illness and conditions related to hospitalization and treatment (Trevisana et al., 2019).

By facilitating involvement in occupations, these professionals modify the ICU routine, providing the individual with control over their body and decisions, reflections on the health-disease process, social participation, among others. Upon initiating occupational-therapeutic interventions in the ICU, motor, procedural, and social interaction performance skills are stimulated, in addition to training in occupations, which enable a shorter post-discharge rehabilitation process, thus reducing the risk of readmission (Teixeira et al., 2017).

To promote a more effective involvement in occupations, the article by Moua (2020), titled “Patient Activation and Engagement (PAE): Guidelines for Acute Care Occupational Therapy Practice,” points out guidelines involving the creation of goals and multidisciplinary treatment plans centered on the person, especially for those who present difficulties in occupations, providing alignment between the care strategies that can be offered and the individual’s goals, thus fostering better occupational involvement and satisfaction.

Given this, occupational therapists play a crucial role in patient care during ICU hospitalization, as their therapeutic process consider the bond between the therapist and the patient and their professional values included the guarantee of engagement in occupations considering the person’s abilities, factors, and contexts, which enable a more comprehensive care (Moua, 2020; American Occupational Therapy Association, 2020).

Strategies like these are important, as alongside the technological resources of an ICU and its teams, there are the health service users – individuals endowed with subjectivity and uniqueness that are mobilized by the context in which they inserted (Damion & Moreira, 2018) and should be understood in all their dimensions as beings who can choose and make decisions in the face of the difficulties encountered (Souza et al., 2021).

In this study, the person is understood in their totality, composed of three dimensions that are indivisible and interdependent: the biological, the psychological, and the spiritual or noetic. The biological dimension encompasses bodily phenomena; the psychological dimension refers to feelings, sensations, desires, and conditioning; the spiritual or noetic dimension is characterized by free decision-making in the face of life’s adversities (Stockinger et al., 2022).

This understanding of the person underpins Logotherapy and Existential Analysis, which refers to a psychological school of phenomenological, existential, and humanistic character, also known as Psychotherapy and Meaning of Life or the Third Viennese School of Psychotherapy. It considers humans in their entirety and as capable of enduring suffering, even when life seems to have no meaning (Souza & Gomes, 2012).

Logotherapy was established by Viktor Frankl (1905-1997) – a psychiatrist, neurologist, and professor at the University of Vienna, a Jewish survivor of the Theresienstadt and Auschwitz concentration camps, which served as existential validation of his theories. Through this experience, Frankl points out that a person always has the freedom to choose the attitude they adopt towards the conditioning and circumstances presented by life (Souza & Gomes, 2012).

Freedom within this theory refers to our capacity to choose. However, the foundations show that the idea of responsibility is parallel to freedom, that is, humans are free to choose, but must be aware that they are also responsible for assuming the consequences of their choices (Frankl, 1987). The person is free to position themselves in the face of life’s difficulties, capable of enduring sufferings and finding a meaning in life through the realization of values (Espíndula & Ferreira, 2017).

In Logotherapy and Existential Analysis, values can be creative, experiential, and attitudinal. Creative values, which relate to what a person offers to the world, involve the person’s ability to create something new resulting from concrete activities (Espíndula & Ferreira, 2017; Fonseca et al., 2015). Experiential values are rooted in relationship experiences, in the encounter with the “other”, or in the contemplation of nature, encompassing the sphere of “receiving” from the world (Guerra & Lima, 2016). Attitudinal values refer to the stance that an individual takes towards life when confronted with an unchanging fate (Aquino et al., 2015).

The search for meaning and values in life arises as humans become aware of their finitude, faced with the fact that life has an end (Guerra & Lima, 2016). Thus, it is considered that Frankl’s Existential Analysis provides support to studies involving people in situations of chronic illness, hospitalization, loss, and fear, such as those admitted to a Coronary ICU. Therefore, this study aimed to understand how occupations are experienced by individuals in a Coronary ICU and to address them considering freedom and values.

Method

This is a single case study conducted in a Coronary (ICU) at a high-complexity hospital; the participant was given the pseudonym Helena to preserve her identity. This study was conducted as part of a Master’s thesis in Psychology at the Federal University of Pará (UFPA). It is a qualitative, exploratory, descriptive case study. This method was adopted because it enables a more comprehensive understanding of the experience of hospitalization and how it impacts the occupations and perceptions of people admitted to an ICU in their real context. It is based on the participant’s experiences, opinions, and meanings, aiming to express their subjectivities (Yin, 2015).

The ICU setting has been investigated by the scientific community; however, studies generally present physical and psychoemotional aspects, with few papers addressing the occupational issue of individuals during the hospitalization process (Farias et al., 2023). In this context, the single case study was used as a strategy to investigate how this aspect is presented.

The study was conducted in all its stages by the principal researcher, and only started after approval from two Research Ethics Committees (REC): the Proponent Institution’s REC and the Co-participant Institution’s REC. After gathering all required documents, the project was submitted to the REC of the Proponent Institution and approved (CAAE: 58854022.4.0000.0018). Subsequently, after the submission process, the REC of the Co-participant Institution also approved the project (CAEE: 58854022.4.3001.0016).

After agreeing to participate in the research and signing an Informed Consent Form (ICF), the participant’s medical record was analyzed through the Data Usage Commitment Agreement (DUCA) and the Mini-Mental State Examination (MMSE) was administered. The MMSE was used as an exclusion criterion because of the risk of potential cognitive impairments resulting from the hospitalization process. After that, a semi-structured interview containing closed and open questions was conducted. This script was constructed by the main author and reviewed by a second author to ensure impartiality, aiming to enable the exercise of autonomy and expression of the participant’s feelings, consider the context and experience in the ICU, and to respect the chosen method.

The interview, recorded and later transcribed, was divided into two parts for both construction and implementation during the research. The first part included questions on sociodemographic data such as sex, age, religion, profession, place of birth, education level, marital status, diagnosis, length of hospital and ICU stay, number of hospitalizations and surgical procedures, pre- or post-operative status, and the possibility of getting up from the bed with support and from the chair. These questions were chosen to gather general information, and are complementary to other inquiries related to the uniqueness of occupations in the ICU.

In the second part of the interview, the questions related to occupations in the Coronary ICU included: (1) Would you like to talk about living and occupying yourself while in the Coronary ICU? This question aimed to find out if the participant was willing to discuss her experiences in the ICU and her occupations; (2) Tell me about yourself? This question was intended to make the participant feel comfortable, inviting her to share her history; (3) What were your occupations before you were hospitalized? This query aimed for the participant to express what her previous daily occupations were like outside the hospital; (4) How are your occupations here in the ICU? The participant could describe how her occupations were being managed, her everyday life during hospitalization; (5) What is the meaning of these occupations for you? Through this question, the participant would talk about the importance of performing occupations in the ICU; (6) What is the purpose of these occupations for you? This question explored the participant’s purpose and meaning in conducting these occupations in the ICU; (7) If you could choose an occupation to perform at this moment, what would it be? This aimed to have the participant mention a significant occupation she missed and wished to resume while in the ICU; (8) To perform a value is to offer something to the world. When you occupy yourself here in the ICU, are you offering something to the world? This question intended for the participant to identify, through her occupations, what she might be offering to the world, realizing values; (9) Is there anything you would like to share?

Lastly, a free expression activity was conducted to learn about the occupations undertaken in the Coronary ICU, with the following initial instruction given: “Now, I invite you to express your routine in the ICU, your occupations, your everyday life here. Feel free to use the following materials.” Various materials were offered for the activity, such as A4 paper sheets, gouache paints, brushes, various colored pens, a ruler, a pen, colored pencils, crayons, white glue, a pencil, an eraser, and scissors. It is worth noting that a small, separate, and sanitizing kit was provided to the participant, and after the meeting, she could keep it or dispose of it to prevent infection.

To conclude the proposal, the following questions were asked: (1) Can you tell me what you have done? This question facilitated verbal expression and the participant’s opinion about her creation; (2) What was it like participating in this activity? This question aimed to learn the participant’s opinion about the proposal; (3) How did you feel? This question was intended to discover the feelings, sensations, and perceptions that arose during the activity; (4) How was it for you to talk about your occupations here in the ICU? In this final query, the participant would discuss her occupations in the ICU. The final production of the activity was photographed, and the dialogue was recorded.

In the literature, several authors have used this type of activity as a data collection instrument with similar materials, such as Corrêa (2009), Souza (2014), and Gomes (2021). In this study, it was observed that the free expression activity promoted the expression of thoughts, feelings, needs, and existential aspects, in addition to fostering autonomy and control of oneself and the resources used. Furthermore, this activity was perceived by the participant as a moment of listening, attention, care, and relaxation.

We present the case of Helena—a participant who, from the beginning of her contact with the researcher, showed interest in the research, was welcoming, motivated, and willing to share her experiences in the ICU in detail, demonstrating how the ICU impacts her occupations. Moreover, she brought a repertoire of occupations prior to hospitalization that had been marred by adversities, but at that moment, were being redefined through the realization of values during her hospital stay.

Helena captured the researcher’s attention because, even in an ICU environment with all its restrictions and the impacts she had previously experienced, she chose to occupy herself with caring for those around her, including both healthcare professionals and other patients. By offering her attention, care, and prayers, she engaged in attitudinal and creative values, overcoming and finding new meaning in the suffering of ICU hospitalization.

Case Presentation

The Helena case: overcoming life’s adversities

Helena is originally from Belém, state of Pará, and was 64 years old at the time of the study. She has two children, and is a widowed housewife, but is not retired. She is Catholic. Sha has completed primary education up to the 5^th grade (equivalent to complete Elementary School in the US). She was admitted to the Coronary ICU because of an acute myocardial infarction (AMI) on the fourth postoperative day following a coronary artery bypass grafting (CABG) surgery. She scored 23 points on the MMSE, which indicated that she was oriented in time and space, with intact language and memory, and thus able to respond to the interview.

At her first meeting with the researcher, Helena was found sitting up in bed, with her head raised, showing appropriate vital signs and a chest drain, demonstrating that she was conscious and alert to who was entering and exiting the ICU, and in good spirits. When invited to participate in the study, she appeared enthusiastic and welcoming towards the researcher—who conducted the informed consent process—and agreed to participate in the study.

When the interview began, she mentioned that she was a homemaker living with her 22-year-old grandson, whom she had raised from infancy. She then shared information about her husband, explaining that she used to live with him and their grandson, but he had passed away about a year ago as a result of complications from COVID-19. She mentioned that they had lived together for 25 years with their two children, but currently, neither of them lived with her.

During the initial minutes of the first meeting, as Helena observed the movement around the ICU, since her bed was near the unit’s entrance and exit, she prayed to God asking for help and care for all the hospitalized patients. Observing a person next to her undergoing hemodialysis, she stated that her husband also needed this treatment while he was ill. At this point, she spoke about her husband’s illness, with tears in her eyes and a choked voice. She provided details about the diagnosis—describing it as “water in the spleen”—and the multiple hospital visits without a precise diagnosis, until the prognosis worsened; however, she did everything she could and left her husband in the hands of God.

Helena said that her husband had always been very good to her and their family. The couple had a very strong bond and a deep love, as when he was hospitalized and near death, she felt him saying goodbye while she was at home. She recounted this episode in great detail, mentioning that she was sitting on the bed hemming her grandson’s pants around midnight. However, something told her to get up and take a shower, as it was not like her to be “lying around” that way. So she decided to take that shower, noting that her husband always liked to see her well-dressed and fragrant.

After that, Helena continued describing the event with great emotion, saying that it was precisely at that moment that he came to say goodbye with a tight hug. Overwhelmed and with a choked voice, she crossed her arms as if giving a hug. She confessed that the hug was so tight that she could hardly breathe.

Still emotional, she continued to share that in situations where they were apart and during illness, her husband would let her know, as they talked a lot and had a “sixth sense.” As in the following passage:

Whenever something like that happened, he would come to me, we talked a lot. We both had a sixth sense. We lived together for 25 years; it was a love that only Jesus can erase. He is still in my heart.

Helena mentioned another time when her partner had to be hospitalized. Back then, there were no cell phones for communication. Nevertheless, something warned her that he was hospitalized. And indeed, he was, because during the day’s activities, he felt ill and asked a taxi driver to take him to the hospital.

Next, Helena talked about the illness of her 43-year-old son. She found him lying on the floor, with a long beard, very thin. He remained dependent on diapers, feeding, bathing, and other activities because of an infection. At the time of this study, she reported that her son was at home, already walking with the help of crutches. He was independent for bathing, feeding, dressing, and other activities. Shortly after, she mentioned that one of her purposes in leaving the ICU involved continuing to care for her son.

Helena spoke about the importance of faith, her prayers, and expressed her desire to have participated in the “Círio de Nossa Senhora de Nazaré” (a Catholic religious event that takes place in the city of Belém). However, since she was hospitalized and recovering from surgery, she prayed and pleaded for her healing so that she could participate in the next event.

Helena pointed out the difficulty she faced having received three “blows of life”: the illness and death of her husband, the illness of her son, and her own illness. She revealed she believed these situations were a test from God to see if her heart could endure, and it barely did:

Because you take like three blows all at once, [...]. But it’s a test, right? To see if your heart can take it. It almost couldn’t [laughs]. It almost couldn’t [laughs].

Helena shared that she has always done everything: washing, ironing, cooking, going to the market, bank, church; she always had time to go to church and was generally very active:

I’ve always been very active, always done everything. I washed, iron, cooked, went to the market every Tuesday or Thursday. I set aside Sundays to go to mass. I’ve always made time to go to church.

She lives in a village where her sisters’ houses are located side by side. She is known in the family as a woman of faith, her “nickname,” because whenever someone needed something, they would turn to her, whether to say a prayer or dress a wound.

Helena’s occupational routine before hospitalization involved mainly caring for her grandson, whom she raised and cared for since birth, as her daughter needed to stay hospitalized. She took him home and considers him as her son. Thus, her occupations were organized around her grandson’s work schedule. She woke up at 6 a.m., prepared breakfast for him, and then he would head to work. When he returned at 2:30 p.m., lunch was already ready. He ate, rested a little, and returned to work at 3 p.m.. In the mid-afternoon, Helena prepared a snack for herself and her grandson. She waited for him to return from work in front of the house, where she usually chatted with her sisters. At night, her grandson had a snack, took a bath, and went out to work again. Despite her enthusiastic speech about the activities she performed for her grandson, whom she loved so much, she was very worried while he was working. She prayed many rosaries at different times, followed religious programs on TV late at night, and waited for her grandson to arrive home safe and sound.

Helena said she had always been this way, very concerned about her grandson and the family. She has always put others first in care, and this moment of hospitalization was important for rethinking self-care. She pointed out that on the day of the interview, during the morning visit, her grandson told her that Jesus and Mary had stopped her to reflect and think about life, referring to the process of illness and hospitalization. After a few seconds pause, she nodded in agreement with what her grandson had said.

In early September 2023, Helena fell ill and came to the hospital, where it was confirmed that she had had a heart attack that required cardiac surgery.

Results and Discussion

Adversities, occupations, and losses in the ICU

According to the Léxico Dictionary of Portuguese, adversity means problem, setback, or obstacle (Léxico, 2022). Before her hospitalization, Helena had already experienced several adversities, such as her husband’s death, her son’s illness, and her own sudden illness:

To take three blows all at once, [...]. I was already coming from something bad, because my husband had been hospitalized for five months. Dear, I have a real life story! First, I lost my husband, then three months after that, my son became ill. And then it was me.

The current adversity Helena is facing is her hospitalization in the ICU post-cardiac surgery following a myocardial infarction. Cardiac diseases are serious, represent a threat in all aspects of being, and can bring existential suffering to those affected (Henao-Castaño et al., 2022).

In the ICU setting, various expressions can be associated with existential suffering, such as fear of death and the future; physical decline; loss of self, autonomy, dignity, relationships, and social roles; dependence; lack of power, trust, hope, meaning, and sense of life (Henao-Castaño et al., 2022). In Helena’s accounts, the risk of death is marked with fear:

You know this is intensive, right? You might leave or you might not.

Besides being in the ICU, which is generally associated with death and suffering (Soares et al., 2020), Helena was in postoperative recovery from heart surgery. Cardiac surgery itself can generate anxieties and concerns in individuals, as they may experience situations that affect life and feelings. These situations can occur both pre- and post-operatively, as most of the time, people express doubts regarding their postoperative period with concerns, for example, whether they will be the same after the operation (Oliveira, 2019).

Regarding the losses in this process, Helena described arriving at the surgical ward as losing autonomy and independence when asking for water, as in the account:

— Can I have some water? — No, you can’t! It was 4:30 in the morning when I drank a cup of water. Not a cup, just a little bit, to wet my mouth.

The care provided in the ICU can generate feelings of helplessness and anxiety, especially when it is the first time one is undergoing an invasive procedure (Gimenes et al., 2022).

In the ICU, because of the severity of the clinical condition, the care protocols limit the individuals. Unable to express feelings and preferences, choose how to perform certain occupations, opine and share information about their health/disease process (Gomes & Carvalho, 2018). As Helena reports:

At first, I felt uncomfortable taking a bath in the presence of a young man. Being a 60-year-old lady, on the first day, I thought, [...], oh my God, my God in heaven, my heart.

The feeling mentioned by Helena occurs because of the uncomfortable exposure of intimacy, configuring the loss of autonomy and independence of her own body and the occupation of taking a bath (Costa & Conforto, 2021).

In the ICU, an individual is unable to exercise their abilities, wills, and desires for an indefinite period. During her hospital stay, Helena pointed out the loss of her routine activities, and that she could only sleep, as she describes:

I was energetic, never stopping for a moment [...] life is just sleeping. We get tired, but we can’t do anything.

Daily occupations weave the world we experience every day. Experiences are often seen but not perceived. This is because everyday life is understood as something certain and, often, its complexity, importance, and the necessity of occupations are overlooked (Hasselkus, 2018). Conversely, when illness arises and surgical procedures are needed, thoughts in hospital corridors revolve around a mixture of sensations, meanings, impressions, and perceptions that may be associated with the end of existence, relationships built during life, and everything that is important and significant, including occupations (Brandão Neto, 2017).

Occupations encompass everything that individuals do, so much so that it is theorized that life extends in time and space. Moreover, they can be seen as agents in the construction of identity (Hansson et al., 2022). The interaction between occupation and identity is so consequential that the inability to engage in a meaningful occupation can threaten one’s identity. Likewise, occupation is a means of reconstructing one’s own identity (Hansson et al., 2022).

The occupations that Helena most enjoyed were taking care of her grandson, making his lunch, and washing his clothes. These occupations represented part of her identity as someone who liked to serve and care for others, especially those she considered as her children:

The occupation, well, [...], doing things for my grandson [choked voice and teary eyes], being able to take care of him.

The hospital experience is intense, or at the very least, memorable. It can cause occupational disruption and is another factor for the loss of identity, leading to what the literature calls depersonalization. It is characterized as a stigma in which the individual loses their identity and becomes identified by their bed number or the disease they harbor (Silva et al., 2019). This process occurs from the treatment the person receives during hospitalization, which may infringe upon their space and boundaries, as well as subject them to invasive situations (Silva et al., 2019).

Like Helena, when recounting the bed bath. After a few days, she learned to deal with the need for it to be done by someone else:

So, now after these days, I’ve learned. You know, when we are old, we want to do everything ourselves and we don’t want to show ourselves to anyone, just to our husband. Now, after these days, I’ve learned.

In the ICU, an individual has less control over themselves, although the entire health/disease process has the patient as its main actor. After all, it is in function of their needs that the care process is developed (Damion & Moreira, 2018).

It is noteworthy that, during the data collection process, it was observed that another hospitalized patient had a word search puzzle; however, Helena was not aware that she could have one.

So, on my care day here there’s no puzzle, and I can’t even bring a rosary. I have a cell phone where I put my prayers and I listen to them since 4 o’clock in the morning, but I can’t do that here.

It must be understood that ICU patients require not only treatments based on hard technologies but also human attention and objects, such as televisions, books, and rosaries, as well as moments of interaction, like having a good conversation or listening to music (Cavalcante et al., 2021). The hospital environment offers only limited opportunities for engagement in occupation (Courtney et al., 2000). The routine led Helena to adapt her schedule for praying the rosary:

Here, I try to adapt the times to pray the rosary, I try, right? And I keep up with the team’s routine.

From this account, it was evident that this was seen as Helena’s only possible occupation. It was experienced as a coping tool and a meaningful way to fill the time. The hospital environment, like other physical environments, is filled with social representations and expectations that can guide patient behavior in response to faced challenges. Environmental challenges that exceed a person’s abilities can change the experience of being occupied (Yerxa, 1990; Morville & Erlandsson, 2013). In this regard, it was observed that in addition to facing hospitalization, surgery, and all the feelings and sensations resulting from this process, Helena was also subjected to other losses, such as that of autonomy and independence, occupational routine performed before hospitalization, her identity, and the deprivation of performing meaningful occupations that could have been done in the ICU context.

Freedom and realization of existential values

There are situations that cannot be changed, as well as realities that humans do not choose to witness. However, the capacity to take actions responsibly remains. Helena, even in the adversity she was already facing and the new one – admission to the ICU, was deprived of everything, except the freedom to assume an alternative attitude in the face of the given conditions.

From Frankl’s perspective, freedom can be understood in two ways: “freedom from” and “freedom to” (Aquino et al., 2015). In Helena’s case, she was not free from illness, hospitalization, and losses, but free to position herself in relation to these constraints. As she stated:

I have to be here if I want something in life, to improve my condition as a sick person, I have to stay here.

Freedom is inherent to humans, who are free to make decisions at any moment. They are capable of changing the world for the better if possible, and of changing themselves for the better if necessary (Almeida & Rosa, 2015).

It should be emphasized that while humans are free to choose, they are responsible for their choices, as well as for filling their lives with meaning and effectively realizing values (Moreira & Holanda, 2010). Responsibility lies in the action taken in the present and in the decision of a given person in a particular situation, constituting the act of assuming a mission or responding to life in a conscious manner (Aquino et al., 2015).

Thus, freedom is always linked to responsibility. The freedom to choose and define one’s own life, and the responsibility for the positive or negative outcomes resulting from those choices. Therefore, freedom and responsibility are the essential characteristics of human phenomena (Frankl, 1995).

I will have to stay here so I can at least become half of what I used to be.

Helena exercises her freedom by remaining in the ICU, enduring all the difficulties and adversities that may affect her, and chooses to undergo treatment considering the risks. Thus, she experiences her freedom responsibly, paying attention to the possible consequences of her decisions. It is she who finds the reason to stay, the meaning, even in a situation that causes suffering. Suffering that cannot be avoided, as she needs to be hospitalized to care for and maintain her health.

Regarding the exercise of freedom, a person transcends the limits imposed by illness and hospitalization and assumes the human condition of being in the world. By doing so, they can experience the existential values of freedom of choice and the maintenance of individual dignity as a way to maintain autonomy for themselves and those with whom they interact (Almeida & Rosa, 2015).

In this context, Helena shares a dialogue she had with a fellow patient from the other side of the ICU who she had known since the ward:

I would say: — Girl! Wake up! [gesturing with her hands], wake up, look at yourself here [making a heart sign with her hands], open your eyes, let’s react so we can get out of here.

It is evident that Helena found a way to help and motivate her hospital roommate who was on the other side of the ICU room. She overcame the distance between beds and the difficulty of maintaining contact with others, while revealing such a need. The sense of freedom supported by responsibility enriches human life and is implicit in all decisions made throughout one’s existence (Almeida & Rosa, 2015).

Frankl believes that nothing helps humans overcome illnesses or difficulties as much as the awareness of personal responsibility, the lived experience of one’s special mission (Frankl, 1995), which for Helena was caring for her grandson and son:

So I pray to God that I can leave here, so that I can take care of them.

Helena’s words reflect the capacity of a transformative agent to turn something negative into something positive. By positioning herself with freedom and responsibility, she recognizes that possibilities exist, regardless of the limitations imposed by technology, intensive care, and impersonality in the ICU. The ability to confront adversities and losses in the ICU represents the highest value to be realized, as it encompasses existential decision-making. This is not only based on rational and cognitive will, but on intuitive will, which stems from the spiritual unconscious, the existential core of the person, and the noetic or spiritual dimension (Guedes & Gaudêncio, 2012).

The noetic dimension distinguishes humans from animals. It involves taking a stance on physical conditions and psychic existence, as well as personal decisions regarding will, intentionality, practical and artistic interest, creativity, ethical sense, and value understanding (Guedes & Gaudêncio, 2012). Through this dimension, humans become capable of embracing values and finding meaning – beyond being free, they are essentially intentional and transcendent beings (Dittrich & Oliveira, 2019).

The path to realizing values is not like a cake recipe. Everyday experiences raise questions that people feel obliged to answer, as life is a continuous process of questions and answers that persists throughout one’s lifetime (Rech, 2017). Answers can only be offered by responding to life, which means taking responsibility for one’s own existence. Helena responds:

Dear, I believe God has everything planned for our lives. Since He put me here, He knows what he has to give me. He will provide the blanket when He sees it is cold. So he’s holding me here.

Beyond the attitudes described by Helena, which constitute attitudinal values, Frankl (2015) also mentions, among other things, the contemplation of nature, like a sunset, as constituting experiential values. In the ICU, Helena had a chance to see the sun for a few minutes while doing physical therapy. During her dialogue with the physical therapist, she expressed interest in seeing the sun, and the professional took her to an outdoor area.

Franco et al. (2020) used a bedside board that was filled out by the patient with the question: “What is important to me today?”. Seeing the sun was present as a requested activity, as well as seeing family, walking, among others. Understanding such expressions allows for the realization of the necessity for comprehensive care beyond physical needs.

For those in the ICU, seeing the sun is important. Amidst technological devices, noise, and the cold, contact with nature provides visual, thermal, and psychological comfort. It allows the patient to visualize the outside of the hospital, the external world, and aids spatial-temporal orientation, which contributes to their well-being (Escoqui & Lima, 2019).

For Helena, seeing the sun was so important that she considers that moment and the professional as sources of inspiration:

Then she took me to the sunshine, [...], so, I mean, she was my inspiration. I wanted to, but I didn’t know if I could. Because, you stay here and you don’t know, do you?

Helena values the support of the healthcare professional who allowed her to breathe outside the ICU and contemplate the sun for a few minutes, contributing to the realization of experiential values. This value profoundly impacted Helena, guiding her towards finding meaning and redefining her experience, and it was an innovative experience for her in the ICU. Frankl also points out that serving the community is a source of value realization (Frankl, 2015). In her everyday life, Helena already embodied this value by caring for those in need in her community. In the ICU, by keeping up with the daily routine and conversing with the professionals, she learned that one of the patients had a cardiac arrest. Noticing that the professional—the same one who had taken her to see the sun—was sad and worried, Helena offered support and invited her to pray, as described in the following account:

“Doctor, calm down, calm down. Shall we pray?” She came with me and we prayed [...]. So it means that we made a prayer group, [...]. That was very good!

Helena showed herself to be available to help others. She participated in a voluntary act with the medical and physiotherapy team on behalf of another patient, which constitutes the realization of creative values by offering something to the world. At that moment, she expressed how good it felt, as if fulfilling her existence. This value, like experiential values, is directed towards self-transcendence. When Helena is in the sun, prays, and asks for blessings from God for other patients and for the professional accompanying her, and in the value of creation, she directs her thoughts and the routine of her prayers to the patient who needed it most at that moment.

Beyond the values expressed, when Helena was asked if she considered that she was realizing values, she referred to the experience of offering something to the world, sharing the ICU experience along with the learning and reflections from this period of hospitalization. Such action brings her closer again to experiential values:

For me, it was greater, I learned more about dealing with human beings, valuing, do you understand? To value things, because nowadays, you think, I have this, [...], that, [...], I have money, [...]. You can have whatever, but [...]. There’s nothing that can buy, my dear, this here that I'm living.

When Helena talks about goods and wealth, she approaches what Frankl described concerning hypermodern social configurations. Human existence increasingly turns towards pleasure and self-realization based on material goods. However, the pleasure gained through acquisitions quickly dissipates, and what remains is only existential emptiness (Ramos & Rocha, 2018).

Helena showed admiration for living experiences because, before hospitalization, she had a different view of the ICU, and this environment was redefined through the realization of values by finding meaning:

My grandson said that Jesus and Mary stopped me to reflect and think about my life because I always think of others and never about myself [pauses to breathe and nods in agreement with the grandson’s statement].

The experience, through the realization of values, was significant for Helena. When asked to represent her routine of occupations in the ICU, she produced the following in the second meeting during a free expression activity, as illustrated in Figure 1 (Supplementary Material). When asked about what she produced, she reported representing herself happily alongside her partners from the UCA. She chose the word “gratitude” for the help of all the professionals in her recovery, and added:

And I want to pass this on to my friends, to all of them, from the doctor, I feel fulfilled because my situation is difficult, but not impossible, as long as you have faith.

Helena’s faith, according to Frankl, emerges from personal freedom, not from family impositions or cultural contexts shaping one’s life. True faith, as a relationship with what is considered sacred, springs from internal freedom (Carrara, 2016). For Frankl (2008); spirituality is not about any specific religion or religious belief, but pertains to human openness to transcendence (Carrara, 2016). Thus, the founder of Logotherapy sees a connection between spirituality and the psychological health of humans.

Reflecting on the results and discussions generated, this study highlights certain limitations and the need for future research. One limitation is that this is a case study. In future research, case studies could be used as an exploratory phase, aiming to identify observation categories and generate hypotheses. Additionally, other methods that enable the analysis of a larger sample could be employed.

Another limitation of this study was that there was only one encounter, consisting of an interview and a free expression activity. Sometimes, the routine of an ICU and the clinical condition of the patient may not allow the time needed for these two phases, which can lead the participant to quickly conclude the tasks.

Furthermore, the profile of the Cardiac ICU and post-surgical patients can make it challenging to find eligible patients. In this study, the participant was on the fourth day post-operation. Patients with more recent postoperative days might refuse participation or be unable to participate because of pain, cough, postextubation consciousness fluctuations, and alterations in rest and sleep patterns.

In the ICU where this study was conducted, patients typically are discharged by the fifth postoperative day if they are hemodynamically stable. Therefore, for future research, it is suggested that the first stage—the interview—be conducted in the ICU, and the second stage—the free expression activity—be conducted in the ward.

This issue arose because the researcher was not an occupational therapist employed by the institution; thus, care protocols and indicators such as extubation time, rehabilitation, and postsurgical discharge time can vary from one hospital to another. Moreover, hospital infection control protocols might not authorize the entry of the materials used in the free expression activity. Therefore, it is suggested that one of the study steps include an institutional visit to understand the ICU routine and its specificities, and to converse with occupational therapists about potential updates to care protocols or that the researcher be actively working within the institution.

Conclusion

The ICU environment significantly impacts occupations, causing feelings such as fear, anxiety, isolation, loss of autonomy, and independence. However, through the capability of the noetic dimension, it is possible to overcome adversities, realize values, and find meaning in life. It has also been observed that the ICU can be a modifiable environment where occupations of interest to the hospitalized person can be conducted, and when this happens, there is a potential for value realization.

The accounts from the participant in this study are significant in the context of current hospital realities, in which care processes are heavily based on scientific protocols, primarily focused on the biological aspect, which aims to heal the patient. These processes are considered of crucial importance for care; nevertheless, equally important are the care strategies that involve all aspects of the person, including their psychological, spiritual or noetic, and occupational dimensions.

This comprehensive approach to patient care emphasizes the importance of treating the whole person, not just the illness. It acknowledges that while the biological recovery is paramount, the emotional, spiritual, and occupational well-being of patients plays a critical role in their overall recovery and quality of life. Therefore, incorporating activities that engage these aspects can significantly enhance the healing process and provide patients with a sense of purpose and control over their situation, even within the restrictive environment of an ICU.

Supplementary Material

Supplementary material accompanies this paper.

Figure 1 Helena's free expression activity in the 2nd meeting

This material is available as part of the online article from https://doi.org/10.1590/2526-8910.ctoAO282836792

• How to cite: Farias, A. A. R., Souza, A. M., & Corrêa, V. A. C. (2024). Occupations, freedom, and values: a case study in a Coronary Intensive Care Unit. Cadernos Brasileiros de Terapia Ocupacional, 32, e3679. https://doi.org/10.1590/2526-8910.ctoAO282836792

• Funding

  This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) – Finance Code 001.

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Edited by

Section Editor

Prof. Carolina Rebellato

Publication Dates

• Publication in this collection
  05 July 2024
• Date of issue
  2024

History

• Received
  09 Nov 2023
• Reviewed
  27 Nov 2023
• Reviewed
  15 Jan 2024
• Accepted
  18 Mar 2024