The purpose of this study was to acquire a deeper understanding of patients' memories of being injured and the trajectory of care before, during and after the ICU stay. The findings show that the injury is not a single event for the patient; it is the start of several events within a trajectory of care and a change of life for the survivor.
When the informants were looking back describing their experiences, they were living with both good and bad memories from the past and with a future that was felt to be uncertain. The trajectory of care drifted between these good and bad memories. The surrealistic world with bad memories was frightening, but there were also pleasing delusional memories such as travelling with the staff who where not causing fear. These good-nature delusions may have given some protection from the outside world when the injured person was unable to deal with all the terrible facts. These peculiar experiences can hold a positive potential [17
]. There were two informants with smaller injuries who told us that the nightmares from the ICU returned when they suffered from stress or got tired at home. It is possible that the two patients may have symptoms of post traumatic stress disorders (PTSD). In a study by Jones et al [18
] delusional memories were a precipitant for PTSD. In contrast to this, in our study the delusional memories from the ICU did not seem to bother most informants after returning home. However informants with delusional memories still remembered them clearly, which is in accordance with findings from a recent study [19
The factual, emotional and delusional memories of the accident and care were at the time of the interview 2–3 years after the injury still important for the informants, but they also struggle with many other problems. There were problems with returning back to work, with disability not being able to do things in the same way as before and there were still memories of the accident with fear evoking thoughts about their own mortality.
Other bad memories were the injured body with its limitations which made them feel insecure and frightened. To be injured is a threat to one's existence. How human beings respond to threats is described by Morse in five different steps [11
] in the extended theory "Responding to threats to integrity of self". The first step is vigilance, followed by enduring to survive, then enduring to live, suffering and finally, learning to live with the altered self. In the present study, we found that all these steps [11
] were identified in the trajectory of care. The vigilance and enduring to survive were shown at the scene of the accident, in the emergency unit, and at the ICU when the informants related their memories from these places where their lives had been in most danger. During the stay in the nursing ward and when the patients realised how injured they were, the focus was on trying to bear it and learning to take it [11
], in other words enduring to live. The suffering and learning to live with the altered self started when they had returned home. The trauma and the recovery from it has also been described as a journey with an event, fallout, and moving-on [3
]. In our study we recognised the three phases of the journey to recovery.
However, we also found that the trajectory of care held different possibilities of and preconditions for care which could produce good memories, something which seemed to be of importance for the injured persons' ability to move on and feel well despite their injured bodies and limitations. This gave us the opportunity to reconsider the care activities within their trajectory.
At the scene of the accident, and in the emergency unit, many patients remembered friendly and caring actions with comforting talk, something which also has been studied earlier [20
]. Our study also shows the importance of putting great effort into locating the relatives as quickly as possible. Uncaring activities in the emergency unit, such as when their clothes were cut into pieces and when they received information about an uncertain outcome, made the individuals feel ashamed and insecure. These actions are in most situations necessary, but they can be problematic when causing a loss of identity and anxiety in a person who already is in a vulnerable situation. The importance of caring encounters and meeting the patients' psychological needs in the emergency care has been described by Wiman & Wikblad [21
In the ICU, care actions such as being considerate and wanting to understand the patients' unreal world with its delusional memories, fear and problems of not knowing what is real need to be improved. The patients' need of true presence from the nurses to feel safe and understood, has also been articulated earlier [22
]. Another care activity which emerged in our study was the facilitation of communication between patients and family during visits in the ICU. The patients often had communication problems due to mechanical ventilation and sedative medication [25
]. The family and loved ones are the ICU patients' lifeline to reality and the nurse should draw the family's attention to this [26
In the nursing ward, caring actions consisted of facilitating a fellowship with other patients with trauma, and of empowering the individuals to move on. The change in the level of care from the ICU to the ward was obvious with both negative and positive memories as a consequence. The transfer from the ICU can be problematic [27
] and in our study the patients realised that they had to find their "new lives" by exercising and getting used to their new body.
After returning home, it was found that informants felt abandoned by the health care system because nobody seemed to be responsible for their rehabilitation and care. The informants and their family seemed to need more support. Jones et al [29
] have described different caring programmes, such as rehabilitation programmes after the ICU care. We suggest that the injured person should receive guidance for a long time, even years, after the trauma, this has also been articulated earlier [30
]. Having a supporting family and friends was the most important part of being connected to gratitude for life and to move on, focussing on the future. This study supports Maddox et al [8
] findings of the relatives' importance to the patients. Those informants who were not able to move on seemed to be without caring families, and their injured bodies seemed to bear an injured spirit, thus becoming an injured person. When bad memories are balanced by good ones, there are more possibilities to move on towards an uncertain future after the injury and the ICU care.
We considered it important to focus on memories from different scenes from the trajectory of care. Therefore it was of interest to gain knowledge about the patients' memories from events of this trajectory, because such knowledge could lead to a development of caring actions that patients will remember, and remember favourably. In this study, one important finding was the informants' memories of knowing that other people, such as care providers, family, and "the man on the street" took care of them when they needed it, giving them confidence in knowing that "no man is an island". Being in need of help can be seen as an ethical demand [31
]. This demand was here implicit and brought about by the informants putting their lives in the hands of the medical staff, trusting the notion that each human being is considered to be responsible for the "other". This is based on an assumption of a spontaneous manifestation of life involving confidence, trust and love. These traits are per se ethical and characterised by an idea of reciprocity between human beings. Human life implies that trust between individuals is elementary. To show trust means to expose yourself. Should a person remain unaffected by this exposure, the trust has been abused. If the staff appeared unaffected the informants felt offended or abandoned by the staff. Such activities could be regarded as uncaring.
Good caring actions as well as family support resulted in that patients felt cared for and safe, which made them realise that they fitted in just as they were. It seemed to be important for the informants in this study to have good memories of care and of human love to counterbalance those memories of the surrealistic world and of living with an injured body.
In the present study only three of 18 patients were suffering from total amnesia for several weeks. Amnesia can be rather common for patients with trauma [32
] but in our study there were also patients without mechanical ventilation. This might be the reason for the better recollection and that the delusional memories were still very clear for all. For those patients in this study who had amnesia it was a relief not to remember the accident. However it was important that family members and nurses told them what had happened when they were in care. These stories from others enabled them to create their own history around the trauma and the care, as well as letting them know that they were loved. This became these individuals' being in the world [14
We had to consider some methodological issues. Our aim was not to seek the ultimate interpretation, but to seek one out of many possibilities related to what is said in the text. We also sought the most useful understanding in relation to our own pre-understanding. To broaden our pre-understanding, and hence the possibility to interpret the text in a relevant manner and reach new understanding, we used previous theoretical concepts and models [3
]. When we interpreted the text, we also looked for sub-themes that were contrary to our main interpretation. Finally, it is only when the reader of this research article can make sense of the findings and integrate them in his or her own world that they can be used for improving care [13