Introduction

Cardiopulmonary resuscitation (CPR) survivors, despite their physical and psychological problems, also show positive experiences (Bluvstein et al. 2013). Factors like emotional distress and psychopathology in CPR survivors are related to the urgent need to make growth. This growth arises after the awareness of their death (Ochoa et al. 2017). The survival rate reports from 7 to 26% throughout the world (Miranzadeh et al. 2016), and in Iran there isn’t any exact information. Post-traumatic growth (PTG) refers to positive individual psychological changes due to coping with very challenging conditions such as crisis and stressful events (Calhoun and Tedeschi 2014). According to Cormio et al. (2017), PTG is an individual experience as a result of trauma, and this growth is beyond his/her previous level of functioning, with eventual deeper insight. They go on to state that the traumatic event aimed at the search for meaning with respect to what happened and the management of emotions (Cormio et al. 2017).

Several studies have been conducted among CPR survivors. Elliott et al. (2011) in a systematic review investigated quality of life (QoL) of CPR survivors. They discussed how the majority of studies concluded that QoL after cardiac arrest is good (Elliott et al. 2011). In Sweden, (Forslund et al. 2014) elucidated the meanings of lived experiences of CPR survivors with validated myocardial infarction (MI) etiology. They found two main themes “returning to life” and “revaluing life” (Forslund et al. 2014). In an Islamic context, Moeini et al. (2012) described lived experiences of women with ischemic heart disease in Iran. Five main themes “pain and relief”, “resistance”, “introversion”, “loss of control”, and mutual communication emerged (Moeini et al. 2012).

In Iran Muslims, no study was found that explored PTG among CPR survivors. According to Iranmanesh et al. (2015) a majority of Iranian people consider themselves religious and religious beliefs are often, in an explicit way, integrated into their views and their health beliefs (Iranmanesh et al. 2015). The subjective nature of growth leads to individual, cultural, and religious factors determining the vocabulary used to describe and interpret the experience. Phenomenology is one way of studying phenomena within a culture. The methodology seeks to focus on a person’s experience, which are embedded in culture and religion. This phenomenological hermeneutic study was thus conducted to illuminate the meaning of CPR survivors’ lived experiences of growth in an Islamic context from Iran. Illuminating Muslims CPR survivors’ experiences can help all of the Muslims survivors surrounded the world.

Materials and Methods

Aim

The aim of the study was to illuminate the meaning of CPR survivor’s lived experiences of growth in southeast Iran.

Design

A qualitative approach was used to understand the meaning of CPR survivors’ experiences of growth (Van Manen 2016). The meanings of phenomena cannot be understood if they are not considered through human experiences. When the experience is expressed it can be analyzed as text and considered as the knowledge informants have about that phenomenon (Langdridge 2007). Therefore, open narrative interviews with CPR survivors were used to discover through the stories a world that is further exposed to new interpretations and understandings (Barton 2004). The data were analyzed using a phenomenological hermeneutic approach influenced by Ricoeur (1976). This method provides an opportunity to combine the philosophy of the meaning of lived experiences with a hermeneutic interpretation of a transcribed interview text. The interpretation can create a deeper understanding of the phenomena, based on dialectical movement between understanding and explanation, to a new understanding. In the new understanding, the text is interpreted, based on the researcher’s preunderstanding (Ricoeur 1976).

Data Collection

The CPR survivors’ lived experiences about growth were illuminated by using semi-structured interviews with probing questions, in a private place. All of the interviews were done in the participant’s home. The participants were asked to narrate their experiences of life after survival from CPR. Clarifying and encouraging questions were used, such as “Please, explain more about…” or “Can you provide an example?”

Due to semi-structured interview, the participants state their experience about life after CPR in their own words. Each interview lasted between 60 and 90 min. During the interviews, the researchers tried to keep the focus of the conversation on the aim of the study. The interviews were then transcribed verbatim, and the texts were analyzed using Ricoeur thematic analysis (Lindseth and Norberg 2004). The transcribed interviews were checked with the participants whether there was any ambiguity in the text.

Participants

From winter 2015 to spring 2016, CPR survivors with the following inclusion criteria in southeast Iran were interviewed: (1) being Muslim, (2) 18 years of age or older, (3) being alive and, (4) being conscious. A purposive sample of participants, who had experience of living after CPR, participated in the research. At first, the list of CPR survivors was extracted from the hospitals’ CPR sheets, and then the address and patients’ phone number were obtained. After the call, coordination was conducted for the interviewing session. The participants’ mean age was 49 years, eight of them were male, and the rest were female. The mean time passed from CPR was 21 months (Table 1). After interviewing 12 CPR survivors, we couldn’t find any new subtheme, so data saturation has occurred.

Table 1 Participant demographic
Full size table

Data Analysis

We analyzed the interviews by using the principles of phenomenological hermeneutics influenced by Ricoeur and described by Lindseth and Norberg (2004). The analysis and interpretation of the text involved a dialectic movement between understanding of the whole and of parts of the text through three methodological phases. In the first phase, we read the interviews with an open mind in order to gain a naive understanding of the meaning of life after a CPR. In this phase, there was an attempt to identify an approach for further structural analysis. Research team read the whole text and divided it into meaning units. The units were condensed and interpreted against the background of a naive understanding. We sorted and condensed all meaning units abstracted to form subthemes and themes. Finally, the researchers formulated a comprehensive understanding by contextualization of the text. This step was a sophisticated mode of understanding emanating from and supported by a critical dialectic between the first two phases (Ricoeur 1976; Lindseth and Norberg 2004). The comprehensive understanding was based on a dialectical movement between understanding and explanation, between the whole and parts of the text, and was the final of several possible interpretations of the text upon which we unanimously agreed (Lindseth and Norberg 2004). For data trustworthiness, we checked first codes with participants, and final data confirmed by group of people who were expert in qualitative studies.

Results

Naive Understanding

It seems that growth for CPR survivors in Muslims means a renewed attitude toward death. Most of them no longer have any fear of death. The person’s values can also drastically change, and previous experiences are no longer of interest. There is no motivation to accumulate material possessions or earn vast sums of money; status is no longer of importance and simple things in life, which many take for granted, become very important. They spend more time with their family and friends and became more appreciative of these relationships and all that they have in life. This also developed a deep sense of gratitude for life as well as feeling more love and compassion toward others. They felt a sense of connection with nature and spent time walking in forests, parks and alongside rivers.

Structural Analysis

By structural analysis, we found three themes as described below.

  1. 1.

    Opening up a new horizon in the meaning of life.

    1. (a)

      Changing in the meaning of life Death experience can suddenly put a stop to the mind and its activities. In this respect, silence of the mind clears it out from past interpretations and meanings. Accordingly, all meanings become unexpectedly unstable. A participant with different life style after surviving said:

    I made sense of my own mistakes. I used to try to keep up with the Joneses which was nonsense and illogical; but now, I appreciate the moments of my life.

    1. (b)

      Living in the moment The experiences narrated by CPR survivors seem to manifest a growing appreciation of every moment of life. They also referred to growth as learning from one’s prior mistakes not participating in pointless everyday-life competitions, and being thankful for the remaining moments. A pregnant head nurse said:

    I came back, so I try to make the best use of my time. I appreciate every moments of my life because I know that I will die sooner or later.

    1. (c)

      Optimistic view In CPR survivors, there was a sense of positivity toward everything and even CPR. One of the survivors as an expert nurse said that:

    I can see lots of patients with better conditions than me who didn’t survive. So I cannot be pessimistic towards God. I was 8 months pregnant, but there was no harm to my child.

    1. (d)

      Acquiring lawful properties One of the manifestations of the prosperity of meaning for these participants was attention to the acquisition of lawful properties. They also considered revival as the strongest factor changing the depth of their lifestyle. Furthermore, they considered participation in these competitions only as games with no benefits. One of the rich participants states:

    Before this event, I was full of worldly greed. All my words and thoughts were focused on collecting more money. I also did not care about the lawful and the unlawful. But, I am currently sensitive to gaining lawful revenues. I do not pay heed to worldly properties compared with the time when it was like a money collection competition. I realized that all these events were games and I was only a good player.

    1. (e)

      Satisfaction despite physical problems Most patients had also experienced physical complications of the CPR such as rib fractures. They did not have any complaints because they had led to a higher goal. A man with rib fractures and chest tube states:

    As I became conscious, I had a lot of pain in my chest. My nurse said that the reason for the pain was because of the CPR. Once I realized this issue, I accepted that there were no other alternatives and I was no longer dissatisfied.

    1. (f)

      Giving value to health Giving value to health was an issue mentioned by such patients as another aspect of the meaning of life. They had made attempts to keep their health through sports, especially walking. Some of these individuals who underwent CPR due to drowning were learning to swim. One of the survivors rescued from drowning added that:

    I was drowning because I was not good at swimming; but now, I am learning how to swim. Before this event I did not pay any attention to my health and I did not move a muscle; but now I go walking, and swimming.

    1. (g)

      Replacing mental health with depression According to the statements made by the participants, they achieved mental health by finding the main issue. It is evident that depression is caused by separation from principles and refusing to give up interests. A happy person also has a high rate of life expectancy. Moreover, doubling joy and hope mixed with a sense of mercy and the grace of God for this choice. A participant with depression said:

    I used medications for my depression. After this event, my depression improved. I became oddly hopeful about life because I experienced those moments and I could know what was happening. Since God has selected and rescued me, I believe that He will help me in any circumstance.

    1. (h)

      Morality growth An attempt was made to strengthen good traits in the participants. Increasing patience, giving up pride and forgiving are some of these traits. One of the participants with high morality growth states:

    Now I can suppress my desire and it can elevate my soul. I easily apologize. Forgiveness is more pleasant than anything else for me. After this event, God endowed me with high level of tolerance. For example, death of my parents was with a month of each other I would never have been able to tolerate before.

  2. 2.

    Opening up a new horizon in the meaning of interpersonal connections

    1. (a)

      Serving others a reason for surviving The participants also mentioned the services they had provided for patients suffering from cardiac arrest as one of the reasons for God’s favor to rescue them and highlighted it as a reward for their acts. They believed that life was not a series of irrelevant and meaningless events but a collection of organized happenings that can affect each other. In this respect, the governor of a mountainous rural district stated that:

    I think that helping that elderly woman carry a water pitcher had its own effects and they caused my revival. It was the prayer of a disabled person directing me to do what was required prior to my heart attack and survive.

    1. (b)

      Believing in others’ prayers for surviving Participants also believed that they had discovered the deep meaning of interpersonal relationships and the influence of the hidden layers of these relationships. For example, they assumed that prayers by others especially those by their parents could save them from a heart attack. They believed that such prayers had invoked God to save their life. A survivor from a complicated situation said:

    My mother came and prayed. Her prayers invoked God to save me. I was able to be revived and I began to get better from the moment my mother left me. She said with calmness that I would recover if it’s God’s will.

    1. (c)

      Increasing relation with others The participants also stated that the number of their friends and their social relationships had increased after the CPR. Moreover, they acknowledged that they had become more charismatic than ever before among friends. Helping other and expressing love to them by these individuals was no longer to return it. They found that their relatives could provide more solutions to their problems. Therefore, they were also thinking of appreciating them. A mosque servant said:

    I like to spend time with others. After this event, the number of my friends doubled. I have become more charming to my friends after this happening. My devotion to those around me has also increased because I know that they gave me a hand when I was sick. I did not use to visit my parents a lot but now I almost always ask about their well-being.

    1. (d)

      Participating in charity affairs Participating in charity affairs and taking custody of abandoned children were among the cases mentioned by the given participants. They said that they were trying to do such activities in secret. They believed that doing things in public could lead to hypocrisy. One of the participants with good charity said:

    I went to the charity center and adopted three children. I fear that such activities seem like showing off and hypocrisy.

  3. 3.

    Opening up a new horizon in the meaning of God and spirituality

    1. (a)

      Presence of God The omnipresence of God in all aspects of life was a sign of spiritual growth among survivors. Comparing their life before and after this event had made them believe that all their successes and belongings were from God. They could have never been achieved if there was no act of God. They also considered return to life as an awakening factor to prevent their negligence and pay more attention to God. A man with different view to God states:

    God used to have no place nor importance in my life. I always thought that I could achieve success and I was making efforts and gaining money by myself. After this incident, I realized that all my achievements were the will of God.

    1. (b)

      Connecting to God from nature Realizing the magic power of nature and taking advantage of it was among other manifestations of spiritual growth among survivors. As well, being replete with energy and making sense of the existence of God in nature was one of the indicators of this friendship. It seems that the survivors had gained a more optimistic and deeper look at the issue of existence.

    When I feel distant from God, I immediately go to nature and the surroundings and feel God, I can smell God and I can gain energy. I like to go everywhere and feel God. I used to look at everything superficially but now I look at them in depth. I changed the way I used to look at nature and the mountains.

    1. (c)

      Warning massages from God For these patients, revival from the CPR was taken into account as a turning point to awaken from negligence. In this respect, participants stated that they had already received warning messages from God but they had been unresponsive until the CPR. The patients also stressed that revival from the CPR was a factor making them realize their mistakes and think about a better future. A woman who experienced other events states:

    I had experienced a lot of happenings but they made no difference. When God took my life and returned it, I found that He wanted to say that He loves me. Now, I am seeking forgiveness for my mistakes and I have promised God that I will not commit the same mistakes.

    1. (d)

      Spiritual growth In this study, CPR survivors had reached a high spiritual growth. They tried to keep the signs of this event as a reminder. They believed that attention to God without any warning was a valuable characteristic that could not be acquired by all human beings. A survivor with scars burned on his face said:

    I could have done plastic surgery, but I did not do so. I want to keep such facial scars to remind myself of this happening. I would like to keep it as a warning.

    1. (e)

      Appreciation of God The pleasure of return to life and its sweet taste was so strong that the participants were incapable of appreciating God. Such pleasure is highlighted through looking positive. The range of revival and return to life in such participants was broader than a simple happening (revival and its positive consequences). One of the participants said:

    I think that I cannot express my thanks to God. It is not enough to pray and worship God. I appreciate God for my revival and for the changes that happened after this event.

    1. (f)

      Religious practices One of the things frequently cited by most participants in this study as the meaning of spiritual growth was deeper attention to religious practices, in daily prayers. Practicing religious commandments was also not due to tackling their tasks or having fear of punishment and hope for reward. They wanted spirituality for the senses they had at that moment. One of the old participants said:

    I hardly ever skip my morning prayers even when I am not well. These days, I am the first who gets up to say the morning prayers. I only thank God during my prayers. It calms me.

Comprehensive Understanding

The meaning of CPR survivors’ experience of growth seems to be like opening the doors of perception to the higher reality. The CPR survivors’ lives changed by what happened to them. CPR survivors’ familiar codes of conduct in the meaning of life, spirituality and relationships lost relevance or disappeared as new meanings and values took priority. Such a shift in references points could be interpreted as a shift in their perceptional format. Based on the text, growth means a radical shift from routine habits to become aware of, and open to, higher reality. The rebuilding of the survivor’s inner world, engaging in meaning making in the face of loss, and recognizing the preciousness of life are parts of this shift. They perceived themselves as equal and loving of each and all and openly generous. They tend to “flow” with the natural shift of light and dark and display a more heightened awareness of the present moment and the importance of being in the now. CPR survivors’ experience of growth also means loss of fear of death; strengthened belief in God and spirit, lessened concern for material gain, and greater desire to serve others.

Discussion

The aim of the study was to illuminate the meaning of lived experiences of growth in Iran Muslims CPR survivors. Based on the results, growth referred to promoted level of perception in several life domains. The meaning of growth among the CPR survivors in Iranian society was obtained through in-depth understanding of three domains of “meaning of life”, “God” and “those around them”.

CPR survivors create new meanings for their life. Creating new meanings in this study was reported in the form of appreciating and living in the moment, optimism, life expectancy, no fear of death, and more patience. Their levels of perception had also gone beyond superficial coping with the CPR problems, and they had reached to post-traumatic growth. Meaning therapy can provide a force in every person to go beyond their former abilities and cut across the negative effects of incidents (Frankl 1961). Meaning in the Theory of Health as Expanding Consciousness is defined as “a dynamic process of organizing concerns over time, recognizing patterns, identifying what matters in the moment, and giving energy to new perspectives and directions”. According to this theory, one of the nursing interventions is to help patients find the meaning of life in difficult conditions (Endo 2017). Despite the ability to control some of life’s consequences, survivors are similarly able to control their choices on how to live (Calhoun and Tedeschi 2014). Thus, victims can move from the meaninglessness of life toward a life full of meaning (Janoff-Bulman and McPherson Frantz 1997). They also learn how to live with new life values and change their focus on worries about the meaning of life to creating meaning in their life (Janoff-Bulman and Yopyk 2004).

Besides, the participants in the study experienced living in the moment as one of the important strategies in order to give meaning to their life and to improve the perception of their experiences. It seemed that the study participants could realize the true sense of living in the moment due to encounters with death and touching it closely. Seemingly, they could have the perception that death is always and every moment with them throughout life. According to Bagheri et al. (2018), in Iranian general culture the view of death is tragic, grim and fearful, but CPR survivors to be aware of their impending death without any death anxiety (Bagheri et al. 2018). The concept of living in the moment is also the foundation of meditation. Meditation and living in the moment also mean believing the present time, not caring and not indulging in negative thoughts, having no worries about the future, not thinking about the past, being thankful, as well as having a silent mind. Living in the present time means to expand human consciousness to make the current moment more pleasant instead of throwing it away in order to live every moment of life in reality (Tolle et al. 2010).

Optimism toward life was among the achievements that were consistent with the results of the other studies (Forslund et al. 2014; Ketilsdottir et al. 2014). In this study, a number of patients suffered from severe physical complications on the first few days after revival. These findings were in line with the results obtained in the study by Mehrabi et al. (2016). The main reason for this reaction was their return to life and the second chance to live. Moreover, two of the participants had complaints about physical and psychological problems which were consistent with the findings of other studies in this domain (Forslund et al. 2014; Ketilsdottir et al. 2014; Mehrabi et al. 2016). The survivors believed that more problems could further their patience. The findings were also in consistent with the case study conducted by Bagheri et al. (2016) in Iranian society.

More attention to other in this study was also an interesting point. Enhanced social relationships, attention to issues of family welfare, as well as benevolence to others were considered among the achievements of social relationships. Furthermore, participants in this study had paid more attention to family, while patients revived from ischemic heart disease in Iranian society were seeking for attention from their families in the study by Moeini et al. (2012). Moreover, need for support from family and establishment of good relationships with them had been pointed out in the study by Ketilsdottir et al. (2014). Improved social relationships were also included among issues mentioned by the CPR survivors. The patients in the investigation by Mehrabi et al. (2016) similarly noted improvements in social relationships that were consistent with the findings of the present study.

One of the important aspects of growth in this study was connection to a supernatural power. This aspect had been manifested by highlighting the presence of God in life. These patients could see God’s will behind their revival, and they had tried to learn lessons from this return. In this respect, religious approach was introduced as the most widely used one to cope with diseases and problems in the studies conducted in Iran (Mehrabi et al. 2016; Hassankhani et al. 2010). This issue was also underlined in the study by Joulaee et al. (2012) on experiences of individuals living with cancer in Iranian society (Joulaee et al. 2012). Another aspect of growth due to connection to a supernatural power was attention to nature. Paying attention to nature was to the extent that it had improved their mental performance. Visits to nature can reduce stress accompanied by physiological and psychological reconstruction (Alitajer and Mostaghimi 2016).

Conclusion

Based on the finding of this study, CPR survivors’ experience of growth means a radical shift from routine habits to rebuilding their inner world. It seems necessary that health care workers are informed about these changes so that CPR survivors can be better supported. The finding may assist other CPR survivors to learn from participants in this study. Holding training sessions with an emphasis on meditation education, how to use nature and connecting to God from nature in the adaptation process can have effects on promoting quality of life in CPR survivors.