Meeting the informational, psychosocial and emotional needs of each ICU patient and family

NANDA International nursing diagnoses in the coping/stress tolerance domain and their linkages to Nursing Outcomes Classification outcomes and Nursing Interventions Classification interventions in the pre-hospital emergency care

Aim

To determine the prevalence of NANDA International nursing diagnoses in the coping/stress tolerance domain and their linkages to Nursing Outcomes Classification outcomes and Nursing Interventions Classification interventions in the pre‐hospital emergency care setting.

Design

Retrospective descriptive study of electronic record review.

Methods

Eight thousand three hundred three episodes recorded during the year 2019 were recovered from the electronic health records of a public emergency care agency. The prevalence of NANDA International nursing diagnosis, Nursing Outcomes Classification outcomes and Nursing Interventions Classification interventions was determined. A cross‐tabulation analysis was performed to determine the linkages. Data were accessed in November 2020.

Results

NANDA International nursing diagnoses Anxiety (00146) and Fear (00148) represented more than 90% of the diagnoses recorded in the domain. Anxiety level (1211) and emotional support (5270) were the most recorded Nursing Outcomes Classification outcomes and Nursing Interventions Classification interventions, with almost 20% and 5% of total records, respectively. The linkage between nursing diagnosis Anxiety (00146), outcome Anxiety level (1211) and intervention Anxiety reduction (5820) was the most recorded with slightly more than 3% of the total.

Conclusion

Eight different NANDA International nursing diagnoses in the coping/stress tolerance domain were recorded. Nursing Outcomes Classification outcomes were selected aimed mainly at psychological well‐being and Nursing Interventions Classification interventions to support coping. In general, linkages were aimed to provide emotional support, physical well‐being, information, education and safety.

Impact

This study showed that pre‐hospital emergency care nurses diagnose and treat human responses in the coping/stress tolerance domain. Expert consensus‐based linkages may be complemented by the results of this study, increasing the levels of evidence of both individualized and standardized care plans for critical patients assisted by pre‐hospital emergency care nurses.

Analyses of posts written in online eating disorder and depression/anxiety moderated communities: Emotional and informational communication before and during the COVID-19 outbreak

INTRODUCTION

Moderated online health communities (OHCs) are digital platforms that provide a means for patients with similar medical conditions to communicate with each other under the supervision of healthcare professionals.

AIMS

To examine the impact of the COVID-19 outbreak on content and type of posts published in two moderated OHCs - eating disorders and depression/anxiety - by comparing categorizations of posts written before vs. after the lockdown, and about vs. not about the pandemic.

METHODS

Posts were retrieved from Camoni, the first Israeli medical social network (January-June 2017, March-May 2020). A total of 1475 posts were analyzed. Of them, 802 posts were written before and 680 were written during the first lockdown. Posts were divided into two main categories: informational and emotional, and into fourteen subcategories.

RESULTS

Before the pandemic, the eating disorders OHC was characterized as primarily emotional (emotional: 66.7%, informational: 45.4%) and the depression/anxiety OHC as primarily informational (emotional: 49.8%, informational: 65.8%) (χ² = 31.6, p < 0.001). During the lockdown, there was a transition in the eating disorders community, from primarily emotional to primarily informational communication (emotional: 46.1%, informational: 71.7%) (χ² = 30.3, p < 0.001). In both OHCs, only about one in six posts written during the lockdown was related to the pandemic. There were only minimal differences in subcategorization of posts written before vs. after the outbreak (e.g., searching for medical information was more common during the pandemic: χ² = 40.9, p < 0.001), as well as about vs. not about the pandemic (e.g., sharing negative emotions was more common when writing about the pandemic: χ² = 4.1, p = 0.43).

CONCLUSION

During the first lockdown, people with eating disorders have increased their use of OHCs as sources of informational (as opposed to emotional) support, but the overall impact of the pandemic on the content of posts written in the examined OHCs was minimal, suggesting that OHCs have not changed their function as a valuable means of providing emotional and informational support for people with mental difficulties.

State anxiety, uncertainty in illness, and needs of family members of critically ill patients and their experiences with family-centered multidisciplinary rounds: A mixed model study

This study aimed to determine whether family-centered multidisciplinary rounds could alleviate anxiety and uncertainty in illness and meet needs for critically ill patients’ families. A family-centered multidisciplinary rounds protocol was developed identifying needs of critically ill patients’ families, and family experiences were reviewed through in-depth interviews. A sequential mixed-methods study was utilized, combining survey data and semi-structured interviews in a tertiary medical intensive care unit in South Korea. A structured questionnaire assessed needs, anxiety, and uncertainty in illness for 50 participants. Interview data of 10 participants were analyzed using grounded theory. Assurance was the highest family need, followed by information need. Family needs differed according to gender, relationship to the patient, and length of intensive care unit stay. Participants reported family-centered multidisciplinary rounds provided a sense of relief, a chance to listen to medical staff, and a chance to provide medical staff with comprehensive information about patient care. Proximity needs were found to have a positive correlation with state anxiety, while comfort needs had a negative correlation with uncertainty in illness. Families reported family-centered multidisciplinary rounds were positive, useful experiences. Thus, standardization of family-centered multidisciplinary rounds is needed to meet families’ various needs.

Patient and Family Member-Led Research in the Intensive Care Unit: A Novel Approach to Patient-Centered Research

Introduction

Engaging patients and family members as partners in research increases the relevance of study results and enhances patient-centered care; how to best engage patients and families in research is unknown.

Methods

We tested a novel research approach that engages and trains patients and family members as researchers to see if we could understand and describe the experiences of patients admitted to the intensive care unit (ICU) and their families. Former patients and family members conducted focus groups and interviews with patients (n = 11) and families of surviving (n = 14) and deceased (n = 7) patients from 13 ICUs in Alberta Canada, and analyzed data using conventional content analysis. Separate blinded qualitative researchers conducted an independent analysis.

Results

Participants described three phases in the patient/family “ICU journey”; admission to ICU, daily care in ICU, and post-ICU experience. Admission to ICU was characterized by family shock and disorientation with families needing the presence and support of a provider. Participants described five important elements of daily care: honoring the patient’s voice, the need to know, decision-making, medical care, and culture in ICU. The post-ICU experience was characterized by the challenges of the transition from ICU to a hospital ward and long-term effects of critical illness. These “ICU journey” experiences were described as integral to appropriate interactions with the care team and comfort and trust in the ICU, which were perceived as essential for a community of caring. Participants provided suggestions for improvement: 1) provide a dedicated family navigator, 2) increase provider awareness of the fragility of family trust, 3) improve provider communication skills, 4) improve the transition from ICU to hospital ward, and 5) inform patients about the long-term effects of critical illness. Analyses by independent qualitative researchers identified similar themes.

Conclusions

Patient and family member-led research is feasible and can identify opportunities for improving care.

Transfer out of intensive care: an evidence-based literature review

Critical care beds are a finite resource. Transfer or discharge of patients from the intensive care unit affects the flow of patients in critical care. Effective whole hospital bed management is key to the successful management of the critical care service. However, admission to the critical care unit alone can be extremely frightening, distressing, and traumatic not only for the patients but their families as well. Although transfer to the medical floors is a positive step toward physical recovery, it can be equally traumatic, and many patients and their families exhibit stress, fear, and anxiety. The purpose of this article was to systematically review the effects of intensive care unit transfer or discharge to medical-surgical floors on adult critically ill patients, their family members and nurses.

Important quality aspects in the transfer process

Purpose

– Admission to and transfer from an intensive care unit affects not only the patient but also his or her relatives. The authors aimed to investigate relatives' perceptions of quality of care during a patient's transfer process from an intensive care unit to a general ward.

Design/methodology/approach

– The study had a mixed method design that included quantitative data and answers to open questions. The participants were 65 relatives of patients who received care in an ICU. They were recruited from two hospitals in Sweden.

Findings

– A majority perceived the transfer process as important, but analysis also showed that the participants rated it as an area for improvements. The relatives wanted participation, personal insight and control, respectful encounters, proximity, reassurance, continuous quality, reconnection and feedback. The relatives' participation in the transfer process was perceived as inadequate by 61 per cent, and the support that was received after the ICU discharge was perceived as inadequate by 53 per cent. The patients' length of stay in the ICU affected the relatives' perceptions of the quality of care. Overall, the relatives seemed to desire that the transfer process includes a continuous care, a competent staff, available information throughout the transfer process and personal involvement in the care, both before and after the transfer from the ICU.

Research limitations/implications

– The conclusion of this study is that relatives' needs and seeking for a well-planned ICU transitional process organisation with continuous quality before and after transfer, informational strategies that encourage the relatives to be involved and an organisation with competence throughout the healthcare chain are vital for quality.

Practical implications

– The conclusion of this study is that relatives' needs and seeking for a well-planned ICU transitional process organisation with continuous quality before and after transfer, informational strategies that encourage the relatives to be involved and an organisation with competence throughout the healthcare chain are vital for quality.

Originality/value

– The findings have important implications for nursing and nursing management. A relative's perception of the quality of care before and after transfer from ICU may be a valuable source to evaluate the ICU transitional care.

Patients' and relatives' experiences of transfer from intensive care unit to wards

AIMS

This literature review looks at the evidence around transferring patients from intensive care units (ICU) to wards. The literature informs us that patients and their families experience problems when being transferred from an ICU environment and that this increases overall anxiety.

BACKGROUND

The effects of surviving critical illness often have a profound psychological impact on patients and families This study examines the experiences of adult patients, and their families, following their transfer from the ICU to the ward.

FINDINGS

Five themes emerged from this literature review: physical responses, psychological responses, information and communication, safety and security, and the needs of relatives.

CONCLUSIONS

This review reminds us that these problems can be reduced if information and communication around time of transfers were improved.

RELEVANCE TO CLINICAL PRACTICE

As critical care nurses it is essential that we prepare patients and families for transfer to wards.

Efficacy of information interventions in reducing transfer anxiety from a critical care setting to a general ward: a systematic review and meta-analysis

PURPOSE

Our aim was to undertake a comprehensive systematic review on the efficacy of information interventions on reducing anxiety in patients and family members on transfer from a critical care setting to a general ward.

MATERIALS AND METHODS

MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, and Google Scholar databases from 1990 to January 1, 2011, were searched. Bibliographies of identified articles were reviewed. Only high-quality randomized controlled trials comparing an intervention to reduce transfer anxiety with standard care, where transfer anxiety is measured by the validated State Trait Anxiety Inventory, were included. Data were extracted to estimate standard mean differences (SMDs), pooled odds ratios (ORs), and 95% confidence intervals (CIs) using both fixed and random effects model.

RESULTS

Of 266 studies identified in the primary search, 5 studies enrolling 629 participants met the inclusion criteria, family members' transfer anxiety was significantly reduced in the intervention arm of information provision (OR, 1.70; 95% CI, 1.15-2.52; P = .01) compared with those who received standard care (OR, 0.42; 95% CI; 0.276-0.625; P < .001), and patients' transfer anxiety was significantly reduced in one study.

CONCLUSIONS

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.

Involving users in the development of effective critical care discharge information: a focus group study

BACKGROUND

Discharge from critical care to a general care unit is a difficult period, and more effective information is needed to support patients and their families at this time.

OBJECTIVES

This study sought the views of patients, relatives and health care staff on (1) the most effective methods of delivering critical care discharge information, (2) the required information content of any proposed strategies, (3) the benefits and limitations of any existing strategies, and (4) potential resource implications.

METHODS

In this qualitative focus group study, 11 adult patients, 8 family members, and 23 health care staff in Eng-land took part in 8 focus group interviews at 2 hospitals. The computer software program NVIVO7 was used for thematic analysis of the data.

RESULTS

Three key themes were identified from the data: (1) considerations related to effective discharge information, (2) goals of critical care discharge information, and (3) resource implications.

CONCLUSIONS

This focus group study provides unique user insight into what influences successful and unsuccessful information giving. Based on real experiences, it adds to the limited international body of current evidence. Findings will be of value in designing future critical care discharge information and identifying the related resource implications.

[Needs of the family in the intensive care units: a review of the literature]

Admission to the Intensive Care Units (ICU) is perceived by both patients and their family as a stressful experience. This situation can cause shock, skepticism and anxiety in the patient's setting.

OBJECTIVE

To analyze and present the needs of the family members of the critical patient.

METHODOLOGY

A review was made of the literature in the following data bases: Pubmed, CINAHL, Cuiden and Cochrane Library. Furthermore, three journals specialized in Intensive Cares were reviewed.

RESULTS

After including the articles that met the screening criteria, 30 articles were finally selected. Of these, 11 were reviews of the literature, 7 qualitative studies and 12 more were quantitative investigations. Four groups of needs in the families were identified after the analysis of these articles, these being cognitive, emotional, social and practical.

DISCUSSION

One of the main needs of the family is to receive better information from the professionals followed by the need for closeness with the ill family member. This review proposes that, in order to cover these needs, the information should be protocolized and the visiting hours should be made flexible. Furthermore, incorporation of two familial evaluation tools, the genogram and ecomap, is proposed.

CONCLUSIONS

This work has revealed the importance of having the Intensive Care nurses identify the needs of the family during the admission of the patient in the ICU in order to be able to provide help, support and counseling care that relieves the suffering of the families.

Recovering from the psychological impact of intensive care: how constructing a story helps

BACKGROUND

Numerous studies have demonstrated both the risk of post-traumatic stress as a result of intensive care unit (ICU) treatment and the efficacy of successful narrative processing for recovery from psychological trauma.

AIM

This article is based on recent doctoral research exploring the impact of unanticipated life threats after admission to hospital. It examines the difficulties ICU patients have with constructing coherent narratives of their illness experience and the significance of those difficulties for psychological recovery from critical illness.

METHODS

The original research used a qualitative design blending discourse, narrative, and phenomenological approaches guided by hermeneutical sensitivity to the evolving language of narrative processing. Patients chosen from ICU discharge summaries showing a critical life-threatening event after admission to hospital were interviewed soon after discharge from hospital and then again 1 year later. Unstructured interviews explored participant experience of a critical event and its aftermath.

RESULTS

This article focuses in particular on one finding from the doctoral research. Unanticipated critical illness presented some patients with difficulties in accomplishing the fundamental human task of constructing a narrative of their experience. Risk factors were observed identifying specific vulnerabilities. The extent to which difficulties were overcome impacted positively on the patient's sense of well-being 1 year after discharge.

CONCLUSIONS

In order to recover psychologically, some ICU patients need help overcoming obstacles to their ability to construct an adequately coherent narrative of their experience.

RELEVANCE TO CLINICAL PRACTICE

ICU follow-up clinics could gain increased clarity of purpose from this narrative conceptual framework, eventually evaluating and validating benchmarks for assessing psychological recovery in relation to specified dimensions of narrative processing. Practice development informed by narrative process theory could also enhance ICU nursing communication. Since story construction is central to a person's core identity processes, person-centred nursing would also be implicated.

[Factors influencing relocation stress syndrome in patients following transfer from intensive care units]

PURPOSE

The purpose of this study was to identify the levels of relocation stress syndrome (RSS) and influencing the stress experienced by Intensive Care Unit (ICU) patients just after transfer to general wards.

METHODS

A cross-sectional study was conducted with 257 patients who transferred from the intensive care unit. Data were collected through self-report questionnaires from May to October, 2009. Data were analyzed using the Pearson correlation coefficient, t-test, one-way ANOVA, and stepwise multiple linear regression with SPSS/WIN 12.0.

RESULTS

The mean score for RSS was 17.80+/-9.16. The factors predicting relocation stress syndrome were symptom experience, differences in scope and quality of care provided by ICU and ward nursing staffs, satisfaction with transfer process, length of stay in ICU and economic status, and these factors explained 40% of relocation stress syndrome (F=31.61, p<.001).

CONCLUSION

By understanding the stress experienced by ICU patients, nurses are better able to provide psychological support and thus more holistic care to critically ill patients. Further research is needed to consider the impact of relocation stress syndrome on patients' health outcomes in the recovery trajectory.

The user experience of critical care discharge: a meta-synthesis of qualitative research

OBJECTIVES

This review identifies the most significant factors, which impact upon the user experience of progress and recovery from critical illness during the first month after discharge from critical care, and discusses these in relation to the development of effective critical care discharge support strategies.

DESIGN

Meta-synthesis of qualitative primary research.

DATA SOURCES

Qualitative research published in English between 1990 and 2009 was identified using online databases: CINAHL, MEDLINE, EMBASE, British Nursing Index, CDSR, ACP Journal Club, Cochrane library, Social Policy and Practice and PsycInfo. Studies of adult patients, relatives/carers/significant others, which focused on experiences after discharge from an intensive care or high dependency unit to a general ward were retrieved.

REVIEW METHODS

Following screening against inclusion/exclusion criteria, methodological appraisal of studies was conducted using a published framework. Ten studies met the criteria for inclusion.

RESULTS

Five key themes emerged from the meta-synthesis: physical and psychological symptoms; making progress; the need to know; and safety and security.

CONCLUSIONS

Findings from this meta-synthesis and other related literature supports the existence of physical and psychological problems in the immediate period following discharge from critical care to the ward, and suggests that patients and their families have a desire for more control over their recovery. However, this desire is countered by a need to feel safe and protected, culminating in an expression of dependence on healthcare staff. Any effective support strategy needs to take account of these findings.

Transfer out of intensive care: a qualitative exploration of patient and family perceptions

OBJECTIVE

To examine perceptions of ICU transfer held by patients and their family members, focusing specifically on those aspects of transfer perceived as difficult and those perceived as helpful.

DESIGN

Descriptive qualitative case study design.

SETTING

General ICU of a large regional Australian teaching hospital.

PATIENTS

A total of 7 patients and 6 family members were purposefully recruited at one-month post-discharge from hospital. Participants were selected for their ability to recall ICU transfer, the involvement of family members and their ability to articulate their experiences.

MAIN OUTCOME MEASURES

Two focus groups (one for patients and one for families) were conducted in the hospital setting, aimed at capturing the individual and collective perceptions of transfer out of intensive care.

RESULTS

Four themes emerged from the data that reflected the complex and emotional nature of transfer out of intensive care. These themes included (1) a sense of sudden abandonment (2) pervasive feelings of vulnerability and helplessness, (3) a loss of importance and (4) ambivalence about the experience.

CONCLUSIONS

The need for ICU nurses, ward nurses and affiliated healthcare professionals to provide emotional support throughout ICU transfer is the most significant implication of the study. Strategies to provide this support must be developed, implemented and evaluated.

Reconsidering the transfer of patients from the intensive care unit to the ward: a case study approach

Evidence indicates that the poorly managed transfer of a patient from the intensive care unit (ICU) to the ward can lead to physical and psychological complications for the patient, and often require ICU readmission and rehospitalization. Reviewing this patient transfer process to improve the quality of care would be a positive step towards enhancing patients' recovery and providing skills to staff. The aim of this paper is to review case studies of transferring ICU patients to general wards in order to identify the shortcomings of this process. A literature review was conducted to evaluate current practices in the ICU transfer process. The results of this paper have clinical implications, suggest approaches to improve support for patients and their carers, and provide strategies to improve the transfer procedure.

Patient empowerment: does it still occur in the ICU?

The theoretical underpinnings of patient empowerment were developed through the work of educators and community psychologists, working primarily with the socially disadvantaged. Empowerment is seen as a philosophy based upon the belief of the inherent worth and creative potential of each individual. Therefore, the aim of this paper is to explore whether this creative potential associated with patient choice that encapsulates empowerment is applicable to the Intensive Care Unit.

A qualitative study of the experiences of patients following transfer from intensive care

In nursing literature much attention has been paid to patients' experiences while in intensive care. Extensive literature exists examining the longer-term effects of critical care [Jones C, Humphris GM, Griffiths RD. Psychological morbidity following critical illness - the rationale for care after intensive care. Clinical Intensive Care 1998;9:199-205; Griffiths RD, Jones C. ABC of intensive care. Recovery from intensive care. Br Med J 1999;319:417-429]. There is an apparent scarcity of data examining patients' experiences immediately following discharge to wards. A Husserlian phenomenological approach was utilised to gain some understanding of the experience of patients following transfer from intensive care. Ten patients selected purposively comprised the sample. Interviews were performed on the wards 3-5 days following transfer from intensive care. Data was analysed utilising () [Colaizzi PF. Psychological Research as the phenomenologist views it. In: Valle R, King M, editors. Alternatives for psychology. New York: Oxford University Press; 1978. p. 48-71] procedural approach to phenomenological interpretation and analysis. Three major themes emerged: physical response, psychological response and provision of care. These provide a possible framework for patient assessment. Implications for future practice and study are discussed.

Meeting patient and relatives' information needs upon transfer from an intensive care unit: the development and evaluation of an information booklet

BACKGROUND

Transfer from the intensive care unit to a ward is associated with a significant degree of relocation stress for patients and relatives. This can be stressful for ward nurses due to the dependency levels of patients and the ensuing increased workload. Furthermore the patient may require care, not normally undertaken in that clinical area, e.g. tracheostomy care. Patients may forget the verbal information given to them at the time of transfer and often have limited or no memory of the intensive care unit experience. This can cause anxiety and compound the feelings of stress associated with transfer. Many patients suffer psychological and physiological problems after intensive care unit, which can affect their recovery and quality of life.

AIMS

The aim of the study was to develop an evidence-based information booklet for patients and relatives preparing for transfer from intensive care units.

DESIGN

This collaborative study used an exploratory design with elements of the action research cycle. The study, conducted in three phases, involved identifying patients' and relatives' information needs around the time of transfer; designing and developing an information booklet; and the introduction and evaluation of the booklet into practice.

METHODS

Semistructured interviews were used to elicit the views of patients and relatives regarding their information needs. Members of the multidisciplinary team were involved in identifying and reviewing booklet content.

RESULTS

Evaluation identified positive outcomes relating to patients' and relatives' satisfaction with the information and enhanced communication with other wards and health care professionals. The study also highlighted the need for more staff education in relation to patients and relatives needs when transferring to a ward.

CONCLUSIONS

This study has demonstrated the value of providing patients and relatives with written information regarding transfer from intensive care units. Furthermore the study confirmed the feasibility and importance of including patients and relatives in the process of booklet development to ensure that their needs for information are being met.

RELEVANCE TO CLINICAL PRACTICE

Providing written information as part of a structured discharge plan is recommended. It provides patients and relatives with a resource that they can refer to at any time and that enhances verbal communication. The purpose of this information is to inform and empower patients so that they are better prepared for the transfer and recovery period.

Interfacility transport of patients admitted to the ICU: perceived needs of family members

INTRODUCTION

Limited research has been published regarding the needs of immediate family members with respect to the transport of critically ill loved ones. Furthermore, very little information exists on transport teams members' perception of the needs of the family members.

METHODS

During a 9-month period, a 25-item questionnaire was given to family members of adult patients who were transported by air or ground. All patients were admitted into an adult intensive care unit at a major university teaching hospital. Family members were asked to rank the relative importance of each item with regard to informational or situational needs. The identical questionnaire was given to the critical care transport teams employed by the hospital. The team members were asked to indicate what they thought the family members ranked as important.

RESULTS

Forty-two of 100 family members (42%) returned the questionnaire by mail. All 13 (100%) critical care transport team members completed surveys as well. Statistical comparisons indicated that family members and team members differed significantly on 13 of 25 items. Team members generally underestimated the importance of these items to family members.

CONCLUSION

These findings suggest that, in this sample, transporting crew members often misperceived family members informational and situational needs.

Immediate follow-up after ICU discharge: establishment of a service and initial experiences

Follow-up of patients discharged from the intensive care unit (ICU) is recommended as a means of service evaluation (Department of Health (2000). Comprehensive Critical Care: a Review of Adult Critical Care Services), in order to monitor the quality of the services provided Without patient follow-up, ICU staff have only 'death' or 'discharge alive from hospital' as clinical outcomes from which to judge practice performance, and limited evidence exists on which to base decisions about improvements to critical care practice (Audit Commission (1999). Critical to Success--the Place of Efficient and Effective Critical Care Services Within the Acute Hospital) To address these issues the Regional Intensive Care Unit (RICU) obtained information from patient assessment/interview on problems experienced by patients within 8-9 days (mean), following discharge from RICU A nurse-administered questionnaire was used to identify functional outcomes, nutrition and psychological issues such as anxiety and sleep disturbances Benefits of patient follow-up introduced and planned include: patient diaries for long-term patients, input from clinical psychologis, review of sedation used in RICU.

Understanding collaboration between social workers and physicians: application of a typology

This article builds on prior analyses of data collected from a qualitative study of 50 pairs of social worker-physician collaborators in. This article presents the elements of a typology of collaborators from both professions developed from those analyses. The typology was also applied to the entire sample and each respondent characterized according to type (traditional, transitional or transformational). Further analysis was done to evaluate the relationships between type and collaborative perspectives. The sample was primarily transitional (56%-58%) and there were more traditional social workers (22%) and transformational doctors (24%) than anticipated. Social workers, as a group, were much less satisfied with the doctors than the doctors were with them although both groups of traditional respondents were the most dissatisfied. Both groups were least transformational in relation to control over decision making.

Leaving the intensive care unit: a phenomenological study of the patients’ experience

Discharge from intensive care (ICU), is said to pose difficulties for patients; a phenomenon referred to as "relocation stress". However, this phenomenon has not been fully examined, particularly from the critical care patients' perspective. This study, therefore, explored the lived experience of transfer from ICU to the ward. Phenomenology, based on the interpretative Heideggerian approach was used to guide the study. A purposive sample of six participants was selected. Open interviews were used to collect data. Participants were interviewed twice; once in ICU, prior to transfer, and once in the ward following transfer. The findings revealed that pre-transfer, participants were mainly accepting of their impending transfer. Participants discussed a desire for normality and identified that leaving the ICU staff was the most negative component of transfer. In the post-transfer period, findings revealed mixed feelings regarding the actual transfer. Participants were still suffering from physical complaints, which led to feelings of despondency. Differences between ICU and the ward were also highlighted. Finally, the enormity of the ICU experience appeared to have an impact post-transfer. The results of this study indicate that transfer from ICU can be problematic for some individuals. However, caution is required regarding the use of the nursing diagnosis of relocation stress without obtaining an individual perspective on experiences. Recommendations include the need for greater continuity of care for those recovering from critical illness.

Relocation stress in critical care: a review of the literature

1. Transfer to the ward following a period in intensive care may cause stress for patients. 2. A review of the literature reveals that this phenomenon has been described in a number of different ways, such as transfer stress, transfer anxiety, translocation syndrome and, more recently, relocation stress. 3. This paper reviews the various concepts before arriving at a more operational definition of the phenomenon. 4. It attempts to reveal what causes this phenomenon and to what extent it exists. 5. Patients' responses to transfer are identified and the physical and psychological problems that have been associated with discharge from intensive care are discussed. 6. Lists of interventions that the literature suggests may reduce or prevent this phenomenon from occurring are reviewed. 7. Recommendations for practice development and further research are made.

The meaning of social support for the critically ill patient

Social support has been shown to be important for the critically ill patient. However, what constitutes adequate support for these patients has not been investigated. Thus, the purpose of this qualitative study was to investigate patients' perceptions of their need for and adequacy of the social support received while they were critically ill. Thirty adult patients who were critical during some point of their stay in the intensive care unit (ICU) stay were interviewed, once stable. Interviews were tape-recorded and began with an open-ended question regarding the ICU experience. This was followed by open-ended focused questions regarding social support, such as 'Who were your greatest sources of social support while you were critically ill?' 'What did they do that was supportive or unsupportive?' Data were analyzed according to Miles and Huberman (1994). The categories that emerged were need for social support based on patient perceptions (not number of visitors), quality of support (based on perceptions of positive and negative behaviors of supporters) and lack of support. This study found that quality of support was more important than the actual number of visitors. Patients with few visitors may have felt supported, while those with numerous visitors felt unsupported. Patients who felt unsupported also were more critical of the staff and the care they received. Nurses need to individually assess patients regarding their need for support, and assist family/friends to meet these needs.

Transfer anxiety: preparing to leave intensive care

There is much literature to substantiate the inadvertent emotional and psychological trauma associated with critical care areas. However, alongside this, there is a growing body of knowledge to show that these intense and specialized areas are actually perceived as secure, safe and familiar environments by some patients and family members. Transfer from the intensive care unit is not always perceived in a positive light and often the transition is dreaded by both the patient and his family. The evidence would suggest that discharge from specialized care environments can actually be as traumatic as admission. This phenomenon has become known as transfer anxiety, relocation anxiety, or translocation anxiety. There is the possibility that transfer may induce stress or distress in some patients, especially when routines, environments and/or invasive monitoring procedures are altered or ceased without prior knowledge, preparation or adequate explanation. If healthcare personnel fail to identify and meet the psychological needs of patients and families relocating from these areas, the detrimental effects may extend far beyond discharge from ICU. For relocating patients, transfer from the ICU can be presented as a positive step. However, treatment to minimize transfer anxiety will only be successful when all healthcare personnel recognize and react positively to the psychological factors that affect patients adversely.

Accident and emergency nurses' perceptions and experiences of caring for families

This study is an exploration of accident and emergency (A & E) nurses' perceptions and experiences of caring for families of critically ill/injured patients and suddenly bereaved families. In this study a non-probability convenience sample of 54 nurses working in three A & E departments in Glasgow was studied. A descriptive study design was used and data were collected by use of a questionnaire. Closed questions were statistically analysed using SPSS and open questions were content-analysed into themes and items. Results from the study confirm that participants' perceive of their responsibility to include taking care of patients' families. Participants were familiar with study findings on families' needs and felt that it was important to meet their needs.

Development of a family liaison model during operative procedures

The essence of family-centered care is the provision, by all health professionals, of psychosocially supportive care that fosters family integrity and functioning. Data from a hospital-based satisfaction survey at The Children's Hospital of Philadelphia (CHOP) indicated that the primary reason for parents being "less than completely satisfied" was lack of communication. A search of recent literature suggests also that breakdown in family-centered care in intensive care units is neither new nor unique. The purpose of this article is to describe how efforts to improve communication with parents and families led to the development of a family liaison program and an expanded role for staff nurses in the Cardiac Intensive Care Unit (CICU). The goals of this family liaison program were three-fold: to facilitate establishment of a relationship between CICU nursing staff, parents, and families at the earliest possible point in time; to ensure communication with parents and families at regular intervals during their child's surgery; and to promote practice that incorporates principles of family-centered care within the CICU. The design and implementation of such a program presented nurses in the CICU with both a challenge and an opportunity to take an innovative approach to meeting the fundamental need for information reported by parents and families, and echoed throughout nursing literature. This family liaison program serves to educate parents and families, communicate updates, provide physical and emotional support, and establish continuity of care for the patient and family. Additionally, nurses involved in the program have given positive feedback regarding their expanded role in this family-centered care model.

The challenge of breaking bad news

Critical care nurses will be involved in supporting patients and their families who are receiving, or who have received 'bad news'. This paper will identify the specific challenges faced by critical care staff involved in imparting bad news within an intensive care setting. A framework for practice is shared which might assist them to meet successfully the challenges posed.