The overall search provided a total of 27 articles that met the specified criteria. There are 19 research studies (8 of which are quantitative and 11 are qualitative studies), 4 review of literature articles, and 4 QA/QI/TQM or expert opinion articles. Of the 19 research studies, 17 were conducted by nursing and 2 were done by medicine. The 4 QA/QI/TQM articles and 4 literature reviews are all from the discipline of nursing.
Of the 8 quantitative research studies, 5 are quasi-experimental.28‐32 These studies confirmed the presence of pretransfer anxiety among patients and their families. Gustad et al30 quantified the levels of anxiety experienced by ICU patients just before transfer to the ward and then twice after transfer to the ward to test the hypothesis that anxiety levels would change over the 3 data collection periods. Anxiety was present in 6 (17%) patients at time 1, in 3 (6.8%) patients at time 2, and in 2 (4.5%) patients at time 3. Of the 5 quasi-experimental studies, 3 investigated the effects of individual education using care conferences,28 a structured transfer brochure,31 and an educational booklet.32 The findings showed positive outcomes relating to patients’ and relatives’ satisfaction with the information given and enhanced communication with other wards and health care professionals, and most importantly, pretransfer anxiety was decreased among patients and their families. One quasi-experimental study did not demonstrate a statistically significant beneficial effect of a liaison nurse in terms of pretransfer anxiety to patients and their families.29 Of the 2 survey studies, 1 examined the effects of risk factors on the development of transfer anxiety in patients being transferred from the ICU to the ward,33 whereas the other assessed the problems experienced by patients after discharge from ICU.34 A statistically significant relationship was found between amount of social support, length of ICU hospitalization, and sex with transfer anxiety. Men and those with more social support had a lower chance of developing transfer anxiety.33 The patients also experienced functional, nutrition, and psychological issues after discharge from ICU, which include memories, unpleasant dreams, fear, difficulty concentrating, weakness, pain, appetite changes, and altered sleep pattern.34 The meta-analysis systematically reviewed the efficacy of information interventions on reducing anxiety in patients and family members on transfer from a critical care setting to a general ward. The authors found that providing information to understand a future ward environment can significantly reduce patients’ and family members’ transfer anxiety from the critical care setting when compared with standard care.35
The 11 qualitative studies explored and described the patients’3,6,12,24,36-40 and their families’6,12,39 perceptions of their experiences preparing or being transferred from ICU and the nurses’ experiences of transitional care when receiving a patient from ICU.41,42 One study examined the causes of relocation stress among patients who are for discharge from ICU.36 Findings of these qualitative studies conducted among patients and their families showed that although transfer from ICU may be seen as a sign of progress,39 relocation stress and pretransfer anxiety are present among patients and their families,36 including feelings of detachment and mixed feelings3; physical and emotional responses24; continued experience of dreams, sleep deprivation, pain, and worries38; concerns about rehabilitation from critical care, physiological issues and needs, real and unreal memories, uncertainty, fear, and empathy40; inability to eat, drink, or care for themselves independently, feeling upset after seeing their reflection in the mirror for the first time after ICU, inability to move, change position, or walk leading to anxiety that they will be bedbound thereafter, feeling confused or vulnerable38; and concerns about communication, feeding, change in level and provision of care, ward organization, and environment.24,36,39 Results of the 2 qualitative studies done among nurses revealed that although there are problems and emotions noted and issues with communication,42 the main concern of nurses in 1 grounded theory study was to achieve a coordinated, strengthening, person-centered standard of care to facilitate patient transition.41 The core category “being perceptive and adjustable” was a strategy to individualize that was related to the other categories: “preparing for a change” and “promoting the recovery.” However, the nurses were forced to “balance between patient needs and the caregivers’ resources” and consequently were compromising their care.41
The key topics discussed in the 4 literature review articles were the following: relocation stress and to determine what causes it43; identify the factors impacting discharge from ICU8 and problems of the discharge process44; and present a conceptual framework that explains the effect of the concept of “uncertainty in illness” and anxiety as these may apply to the families and their transfer needs from ICU.45 Transfer out of ICU is a significant anxiety-producing event for patients and their families. The phenomenon “relocation stress” has been described in a number of different ways, such as transfer stress, transfer anxiety, and translocation syndrome.43 Patients’ and families’ responses to transfer are also identified as physical and psychological/emotional problems and environmental stressors that have been associated with discharge from intensive care.10,43 Patients’ and families’ concern for change in the level and provision of care in the medical floors was also illustrated in the literature reviewed. The literature reviews also included the perspectives of nurses. Many ICU nurses reported that they perceived discharge planning as time-consuming, felt uncertainty about the patient’s condition, and lacked a clear idea of the responsibilities in the process.44
There are 4 QA/QI/TQM or expert opinion articles included in this review. The reports focused on identifying problems associated with transfer from ICU and formulating a plan of strategies that will help clinically reduce the issues identified. The strategies initiated were as follows: developing and introducing an information booklet given to patients prior to transfer to the ward46; developing and introducing an advanced practice nursing position—the ICU liaison nurse47; improving the patient transfer process between the ICU and medical-surgical floors using a framework defined by the Six Sigma continuous improvement methodology48; and introducing a formal assessment, consultation, and follow-up process conducted by a clinical nurse specialist (CNS) to facilitate the transition process between the ICU and the medical wards.49 Findings from the review demonstrated that using the Six Sigma continuous improvement methodology phased approach to executing the improvement, patient transfer time from ICU to the medical-surgical floors was reduced from 6 to 2 hours.48 The development and implementation of the ICU liaison decreased postmedical readmissions to ICU from 2.3% to 0.5%; extreme delays were also avoided and nursing overtime was reduced.47 Intensive care unit medical readmissions in 1997 to 1998 were 2.3% before commencement of the ICU liaison role, compared with 0.5% for 2001 to 2002. The identified trend for reduction in ICU medical readmissions is attributed input to patients’ management.47 A systematic evaluation of patients by the CNS, before their transfer from the ICU to a medical unit, has been proven beneficial in ensuring a comprehensive patient care plan. On average, 150 patients are assessed each year by the CNS.49 Cutler and Garner46 articulated that a follow-up investigation and a full-scale research are recommended to investigate the issue of relocation stress more fully and provide valid findings that can extend nursing knowledge in this area. The summary of outcomes or findings from all the papers reviewed is summarized in Table 7.
DISCUSSION AND LIMITATIONS
This review started with PICO questions that are qualitative in nature. Qualitative questions are meaning questions and are rarely asked in evidenced-based reviews.11 Questions asked in qualitative research is not for precise answers testing a hypothesis, rather are necessary when the goal is to describe or understand an experience and the contexts of which the experiences occur and to make known patients’ perspectives of the phenomenon under study.50 The phenomenon under review derived from the PICO questions is the lived experiences of patients, their families, and nurses within the context of ICU transfer and discharge to the medical-surgical floors, which is qualitative in nature that warrants questions asked the qualitative way. It is also noted that although 1 aim for a review is to comprehensively identify all papers on a topic, there are more qualitative evidence included in this study than quantitative. As mentioned previously, as the questions are meaning questions, most of the evidence selected sought to explore, describe, and understand the lived experiences of patients and their families of ICU discharge, including the nurses’ account of transferring and receiving patients. Findings from the qualitative studies demonstrated the presence of pretransfer anxiety among patients and their families; thus, the quantitative studies aimed to quantify the level of anxiety, examined the effect of risk factors associated with the development of transfer anxiety, and determined the impact of interventions that will help reduce anxiety among the patients and their families. These interventions included administering individual and group education through the use of informational booklets and brochures and pretransfer conferences and instituting and implementing a liaison nurse and CNS who can assist with the transfer and discharge process.
This evidence-based review clearly demonstrates the significant importance of qualitative evidence in systematic reviews. Qualitative research has not always been considered sound evidence for practice and has been accorded lesser importance than quantitative research, which has been the gold standard.50 These methodologies are considered weaker forms of evidence compared with other research designs that examine interventions. However, in the early part of the last decade, qualitative research has gained increasing recognition and established a place for itself in systematic reviews. Dixon-Woods and Fitzpatrick51 (p765) stated:
The rigid insistence on controlled trials as the sole source of evidence on effectiveness that characterized the beginnings of the evidence based healthcare movement is fading. Qualitative research is now given explicit consideration in the new guidance. This is consistent with other recent recommendations emphasizing the contribution of qualitative evidence to healthcare evaluation.
The SIGN 50 methodology, from its last revision in 2008, also acknowledged that qualitative methods are increasingly being used to inform practice in some aspects of medical care, but the use of qualitative evidence to identify issues of concern to patients and to help identify key questions to be addressed in the guideline was only becoming an established part of it. There is no updated version of the SIGN guideline yet up to the present. However, it is the methodology used for this evidence-based review. According to Broeder and Donze,50 (p197) whereas quantitative evidence provides the empiric knowing necessary for practice, qualitative evidence supports the personal and experiential knowing critical for practice. In 2009, the Center for Reviews and Dissemination, part of the National Institute for Health Research and a department of the University of York, United Kingdom, established a guideline for incorporating qualitative evidence in or alongside effectiveness reviews. The Center for Reviews and Dissemination presented that there is growing recognition of the contribution that qualitative research can make to reviews of effectiveness, particularly in relation to understanding the what, how, and why.52 Like other groups that seek to move forward to a more inclusive view of evidence, the Cochrane Qualitative Research Methods Group has recently been convened to develop and support systematic reviews of qualitative studies and disseminate the results within and beyond the collaboration’s review groups.50 The group’s focus is on methods and processes involved in the synthesis of qualitative evidence and the integration of qualitative evidence with Cochrane intervention reviews of effects.
Qualitative research is increasingly valued as part of the evidence for policy and practice53 and makes important contributions to the quality of evidence-based practice. The findings of qualitative research often suggest hypotheses that can be tested in future research; the development and validation of instruments have long evolved out of the qualitative tradition; qualitative research can provide the context for evaluating evidence-based practice in nursing; nursing interventions for evidence-based practice can be designed based on qualitative data; and development of new research questions evolves out of qualitative research. The move to recognize the potential value of qualitative research also contributes to the increased diversity of the types of evidence that can contribute to systematic reviews.54
The SIGN emphasized that, after defining the key question, searching, critically appraising, and synthesizing evidence, the next step is to produce recommendations that are relevant and evidence based. Judgment is made on the basis of an objective assessment of the design and quality of each study and perhaps a more subjective judgment on the consistency, clinical relevance, and external validity of the whole body of evidence.10 (p34) Before recommendations can be further discussed, acknowledging the limitations of the review is important. First, only papers written in English were included. The inclusion of studies only written in English and limits within the keywords could have eliminated some appropriate studies. Thesis and dissertations were excluded as well. These papers might have some unique perspectives that will add to the phenomenon and PICO questions under study. Furthermore, the quality of the articles and the small sample size of 27 when excluding the neonatal and pediatric population might have created the potential for limitations in the results. However, it is the opinion of the author that the results accurately represent the quality of the current literature covering this subject.
Because the PICO questions are qualitative in nature and most of the sample evidence is qualitative studies and because of the lack of high-quality, well-conducted randomized controlled trials (RCTs) on which the author had to base the decision-making process, it is not always clear how to arrive at recommendations. To address this problem, the concept of considered judgment was applied as introduced by SIGN. In addition, of the 8 quantitative studies, 5 are quasi-experimental, 1 is a meta-analysis of RCTs, and the other 2 are descriptive surveys. Except for the meta-analysis (graded 1-), all the quasi-experimental studies were graded 2-, and the survey studies were graded a 3, which are low in hierarchy according to the SIGN levels of evidence. The other 8 articles are expert opinions (4 literature reviews and 4 QA/QI/TQM reports), which have an even lower level of grading (level 4) than the other sample studies mentioned. This lack of rigorous, high-quality randomized controlled studies markedly limits the weight of evidence presented and affects the recommendations for practice. This limitation leads to a risk for the systematic review to yield a less balanced analysis that may therefore affect the recommendations resulting from the review. It is important to emphasize though that the grading does not relate to the importance of the recommendation but to the strength of the supporting evidence and, in particular, to the predictive power of the study designs from which these data were obtained. The body of evidence should also be considered as a whole, and one should not rely on a single study to support each recommendation. Thus, the grading assigned to a recommendation indicates to users the likelihood that, if that recommendation is implemented, the predicted outcome will be achieved.10
IMPLICATIONS AND RECOMMENDATIONS
The findings of the studies reviewed demonstrated that transfer out or discharge from ICU to the medical-surgical floors is a stress- and anxiety-producing event to patients and their families. Discharge from ICU is equally as traumatic as admission. Some effects on the nurses are also noted. Although there are positive impact of discharge to the general care unit among patients, their families, and nurses, these are few. It is evident that there are more negative aftermaths of this aspect of care (refer to Table 7). There appears to be a myriad of physical, psychological/emotional, and environmental sequelae as well as effects in the provision of care related to patient’s discharge from critical care. This impact to patients, their families, and including the nurses should be identified and addressed.
The studies reviewed revealed the factors involved in the shortcomings related to discharge process. The literature also showed what contributes to pretransfer stress and anxiety and multiple ways how to decrease it. This topic has been studied on for 4 decades, and yet, clearly, there is a need for more effective, holistic interventions that will bridge the current gap in care.
The ICU discharge process should be an integral and complementary part of the health care matrix.44 In general, discharge planning is initiated from the day of admission and continued throughout their stay not only when they are admitted to ICU but also anywhere in the inpatient units in hospitals or institutions. Discharge planning should also be a collaborative effort between the critical care nurses, physicians, and other ancillary staff. The inclusion of family members in the process is also important. From the results of this evidence-based review, it is evident that the clinical implications of this process need to be addressed and improvements have to be made. Intervention implemented in the past have to be reemphasized and reinforced. There are multiple strategies for improvement of patient transfers or discharge from ICU, including written information or individual education for the patient and family; a standardized communication among staff and caregivers, such as a method of giving nurse-to-nurse report using the Situation-Background-Assessment-Recommendation; use of a liaison nurse such as a CNS; and care conferences.55
Providing education through written materials has shown patient and family satisfaction with transfer or discharge from ICU. Situation-Background-Assessment-Recommendation promotes patient safety because it helps individuals communicate with each other with a shared set of expectations. It improves efficiency and accuracy through the use and sharing of patient information in a concise and structured format like in the nurse-to-nurse report or handovers. The use of a liaison nurse to coordinate the discharge process has both negative and favorable feedback, as noted in the literature. Chaboyer et al29 demonstrated that the use of a liaison nurse did not have a statistically significant beneficial effect on of pretransfer anxiety among patient and families. However, the study conducted by Hall-Smith et al38 showed that the CNS assisted the patients in their transition to the floors and home by acting as a facilitator in the process. Care conferences were also found to be beneficial in reducing the anxiety experienced by family members when the patient is transferred to the general medical floors.28 There are other additional considerations for improvement suggested: looking at the time of day when the patient is discharged from ICU and the suggestion to conduct more rigorous random controlled trials on this topic.
This review indicated the significance of intervention such as an educational brochure or booklet administered to patients and their families; but most of the studies conducted aimed only at measuring and lessening the anxiety of patients and families. Most of these studies are also quasi-experimental. There is a lack of rigorous, high-quality studies such as RCTs, as shown in the low level of evidence ratings on the sample studies included (13 are rated 3 and 5 are rated 2-). Only 1 study, a meta-analysis of RCTs, has a slightly higher rating of 1-. It would therefore be useful to carry out a more rigorous controlled random sample study to ascertain the extent and benefit of intervention programs after transfer from ICU. Therefore, no recommendations will be set forth using the SIGN Grades of Recommendation. Rather, a limited number of recommendations based on the American College of Critical Care Medicine and the Society of Critical Care Medicine 2004 clinical practice guidelines for the support of families in patient-centered ICU will be presented.5 The recommendations fall under the topics family coping and staff stress related to family interactions.
For family coping, the recommendations are as follows:
- Recommendation 1: Nursing and physician staff assigned to each patient should be as consistent as possible. Family members should receive regular updates in language they can understand, but the number of health professionals who provide information should be kept to a minimum.
- Recommendation 2: Family members should be provided with ample information in a variety of formats on emotional needs in the ICU and methods appropriate to comfort and assist in care.
- Recommendation 3: Family support should be provided by the multiprofessional team, including social workers, clergy, nursing, medicine, and parent support groups.
For stress related to family interactions, the recommendations are as follows:
- Recommendation 1: The multiprofessional team should be kept informed of treatment goals so that the messages given to the family are consistent, thereby reducing friction between team members and between the team and family.
- Recommendation 2: A mechanism should be created whereby all staff members may request a debriefing to voice concerns with the treatment plan, decompress, vent feelings, or grieve.
Recommendations specific to the patients, their families, and nurses are also set forth by the author and are summarized in Table 8.
Discharge from ICU has a myriad of impact to the patients and families, including their nurses. Most of the significant effects noted are negative sequelae classified as physical, psychological/emotional, environmental, and effects on provision of care. The review revealed the interventions implemented and recommendations set forth in previous studies. The need to reemphasize and reinforce these recommendations is discussed. Suggestion for further research on the topic was also presented.
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Keywords:© 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Critical care; intensive care unit; transfer