Well-being of critically ill patients in the intensive care unit. A protocol for an evolutionary concept analysis to guide future applications and research.

Aim: To clarify the current meaning of the concept of wellbeing in the context of critically ill patients in the intensive care unit including its antecedants, attributes and consequences. METHODS Design: The study is an evolutionary concept analysis following the method outlined by Rodgers (Rodgers and Knafl 2000; Rodgers 1989; Tofthagen and Fagerstrom 2010) involving the following phases: A) Initial phase, B) Core analysis phase, and C) Further analysis phase (Tofthagen and Fagerstrom 2010; Rodgers and Knafl 2000). The methodological steps of the initial phase involves defining the concept and its associated expressions and surrogate terms, defining the concept’s context, and selection of literature. In the core analysis phase, the literature will be used to describe antecedents, attributes and consequences, and – if possible - identify applications of the concept termed “references” by Rodgers and Knafl (Rodgers and Knafl 2000). In the last phase, questions for further analysis and development are presented, revealing the method’s ability to indicate the direction for further research (Tofthagen and Fagerstrom 2010; Rodgers 1989). Methodologically, the present study will integrate and incorporate both theoretical and empirical elements, as well as qualitative and quantitative sources. Choice of concept and context: This study will focus on provision and perceptions of wellbeing in adult patients during their stay in intensive care units. A priori, we define comfort as a surrogate or related term for wellbeing, which will be included in the analysis to determine how/if they are related. The term “comfort care” is somewhat related, however, according to the National Cancer Institute, it pertains to care given to people who are near the end of life and have stopped treatment to cure or control their disease and may also be called end-of-life care (National Cancer Institute 2025). The term “comfort care” will therefore not be explored in this study. Selection of literature: To establish a credible sample of literature and provide sufficient variation for the analysis, we will select 30-50 papers from the last 15 years where wellbeing and/or comfort have been provided for ICU patients by different health-professional groups and/or perceived by critically ill patients during their stay in the ICU. We will seek to include a broad range of quantitative and qualitative empirical papers, guidelines, editorials, letters, and reviews to illuminate the concept. Furthermore, we will seek geographical and cultural variation and variation in health professional groups when selecting papers for inclusion. Furthermore, we will seek to include highly cited works considered “landmark” or “classic” in the literature about comfort/wellbeing in the ICU (Rodgers and Knafl 2000). Inclusion criteria: Wellbeing and/or comfort are mentioned in title or abstract. Adult patients in an ICU. Time frame: Literature from 2010 and forward. Languages: English and Scandinavian. In addition, we will allow inclusion of papers identified using included papers’ reference lists. Exclusion criteria: Studies pertaining to neonates and children, and End-of-life care (comfort care). Search terms: Literature search and screening: We will search Medline, Cinahl and PsycINFO for relevant papers. Screening of literature will be conducted in Covidence, an online platform for systematic screening and review of literature. All papers will be screened first on the basis of title and abstract by one author, then on the basis of full texts by two authors blinded to each other’s decisions. In case of conflicts, a third author will make the decision. The final consensus on which data to include in the analysis will be conducted with the whole research team. Extraction of data: All included papers will be read in entirety. We will extract the following data: Author, year, journal, type of paper, aim, participants, methods, definitions/ understanding of wellbeing/comfort, including attributes, antecedents, consequences, and examples of application of the concept. Two authors will extract each paper and discuss until consensus has been reached. Analysis: When all included papers have been extracted, each category of data (attributes, antecedents, consequences and references) will be subject to thematic analysis, where each category of data is examined separately to identify major themes identified in the literature and organise data into a cohesive and comprehensive system of descriptors labelling major aspects of the concept (Rodgers and Knafl 2000). Stakeholder involvement: We will seek stakeholder consultation with patient and family representatives to reflect on the selected concept and context, and the major aspects identified in the literature. Inputs from the patient and family representatives will be used in clarification or additions to the chosen concept and analysis.