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

Co-development of a transitions in care bundle for patient transitions from the intensive care unit: a mixed-methods analysis of a stakeholder consensus meeting

Background

Intensive care unit (ICU) patients undergoing transitions in care are at increased risk of adverse events and gaps in medical care. We evaluated existing patient- and family-centered transitions in care tools and identified facilitators, barriers, and implementation considerations for the application of a transitions in care bundle in critically ill adults (i.e., a collection of evidence-based patient- and family-centred tools to improve outcomes during and after transitions from the intensive care unit [ICU] to hospital ward or community).

Methods

We conducted a concurrent mixed methods (quan + QUAL) study, including stakeholders with experience in ICU transitions in care (i.e., patient/family partners, researchers, decision-makers, providers, and other knowledge-users). First, participants scored existing transitions in care tools using the modified Appraisal of Guidelines, Research and Evaluation (AGREE-II) framework. Transitions in care tools were discussed by stakeholders and either accepted, accepted with modifications, or rejected if consensus was achieved (≥70% agreement). We summarized quantitative results using frequencies and medians. Second, we conducted a qualitative analysis of participant discussions using grounded theory principles to elicit factors influencing AGREE-II scores, and to identify barriers, facilitators, and implementation considerations for the application of a transitions in care bundle.

Results

Twenty-nine stakeholders attended. Of 18 transitions in care tools evaluated, seven (39%) tools were accepted with modifications, one (6%) tool was rejected, and consensus was not reached for ten (55%) tools. Qualitative analysis found that participants’ AGREE-II rankings were influenced by: 1) language (e.g., inclusive, balance of jargon and lay language); 2) if the tool was comprehensive (i.e., could stand alone); 3) if the tool could be individualized for each patient; 4) impact to clinical workflow; and 5) how the tool was presented (e.g., brochure, video). Participants discussed implementation considerations for a patient- and family-centered transitions in care bundle: 1) delivery (e.g., tool format and timing); 2) continuity (e.g., follow-up after ICU discharge); and 3) continuous evaluation and improvement (e.g., frequency of tool use). Participants discussed existing facilitators (e.g., collaboration and co-design) and barriers (e.g., health system capacity) that would impact application of a transitions in care bundle.

Conclusions

Findings will inform future research to develop a transitions in care bundle for transitions from the ICU, co-designed with patients, families, providers, researchers, decision-makers, and knowledge-users.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07392-2.

The expressed support needs of families of adults who have survived critical illness: A thematic synthesis

BACKGROUND

Surviving critical illness can result in ongoing psychological, physical and cognitive impairments for both survivors and families. During the time from the critical illness through to the period of adaptation back to community living, families, alongside survivors, have support needs.

OBJECTIVES

This systematic review aimed to provide an in-depth insight into the expressed support needs of families of adults who survived an admission to an intensive care unit and returned to a home environment. It also aimed to explore how these needs change over time, and what support provisions families perceived to be helpful.

METHODS

This was a systematic review using thematic synthesis methodology. Predefined searches were conducted in CINAHL, Medline, PsychINFO, SocIndex, EMbase, Academic Search Complete, EThOS and OpenGrey to locate studies published in English from 2000. Two reviewers screened each study against the inclusion criteria. Quality appraisal was undertaken using Joanna Briggs Institute tools. Extracted data were managed in Nvivo12® and analysed to identify descriptive and analytical themes. The Timing it Right Framework was used to frame changes in need across the recovery continuum.

RESULTS

Thirty-nine studies were included, 30 qualitative, eight quantitative and one mixed methods. Five key family needs were identified across the recovery continuum: for security; to make sense of the situation; finding a balance; holding everything together; and for trust.

DISCUSSION

Families found the following interventions helpful: written information; care coordination and navigation; input from intensive care staff after discharge to support continuity; and provision of family support groups. Although there are similarities between the needs of families and survivors, there are sufficient differences to warrant the development of processes to identify and address family need throughout the recovery continuum.

CONCLUSION

More research is required to develop a tool to better identify the needs of families across the recovery continuum, identify gaps in current service provision, and design interventions to meet these needs.

STUDY REGISTRATION

CRD42019136883 (PROSPERO).

Development and evaluation of brochures for fall prevention education created to empower nursing home residents and family members

AIMS AND OBJECTIVES

In this study, we describe the development of evidence- and theory-based fall prevention educational material and its evaluation from the users' perspectives.

BACKGROUND

To reduce risk factors for falling in nursing homes, nursing staff must enact multifactorial fall prevention intervention programmes. A core component of these programmes is to educate residents and their family members, both verbally and in a written form. However, users can only benefit from educational material if it is based on current scientific evidence, easy to understand and process and customised.

DESIGN

We followed a structured procedure during the development process, while considering various aspect of quality. To assess the understandability and usefulness of the resulting educational materials, we conducted a qualitative content analysis study.

METHODS

The educational materials development process incorporated several iterative steps including a systematic literature search and the application of frameworks for designing and writing the materials. To evaluate the material, we performed six focus group discussions separately with residents, family members and nursing staff from two nursing homes (total of 32 participants).

RESULTS

Residents' brochures included clear information on avoiding external risks as well as coping strategies after a fall event. Family members' brochures were more comprehensive, including both concrete tips and outlining the advantages and disadvantages of interventions. Residents and family members had no difficulties understanding the material and tried to apply the content to their individual situations. Nursing staff commented on some ambiguities and incongruities relating to current nursing care practice.

CONCLUSIONS

By involving users in the development of evidence-based educational materials, nursing staff can achieve a high acceptance rate for the materials and motivate users to address the topic.

IMPLICATIONS FOR PRACTICE

The involvement of users is essential for developing educational material that meets users' needs. Educational material should be used as part of an overall strategy to educate residents and family members in nursing homes.

Using an intervention mapping approach to develop a discharge protocol for intensive care patients

BACKGROUND

Admission into an intensive care unit (ICU) may result in long-term physical, cognitive, and emotional consequences for patients and their relatives. The care of the critically ill patient does not end upon ICU discharge; therefore, integrated and ongoing care during and after transition to the follow-up ward is pivotal. This study described the development of an intervention that responds to this need.

METHODS

Intervention Mapping (IM), a six-step theory- and evidence-based approach, was used to guide intervention development. The first step, a problem analysis, comprised a literature review, six semi-structured telephone interviews with former ICU-patients and their relatives, and seven qualitative roundtable meetings for all eligible nurses (i.e., 135 specialized and 105 general ward nurses). Performance and change objectives were formulated in step two. In step three, theory-based methods and practical applications were selected and directed at the desired behaviors and the identified barriers. Step four designed a revised discharge protocol taking into account existing interventions. Adoption, implementation and evaluation of the new discharge protocol (IM steps five and six) are in progress and were not included in this study.

RESULTS

Four former ICU patients and two relatives underlined the importance of the need for effective discharge information and supportive written material. They also reported a lack of knowledge regarding the consequences of ICU admission. 42 ICU and 19 general ward nurses identified benefits and barriers regarding discharge procedures using three vignettes framed by literature. Some discrepancies were found. For example, ICU nurses were skeptical about the impact of writing a lay summary despite extensive evidence of the known benefits for the patients. ICU nurses anticipated having insufficient skills, not knowing the patient well enough, and fearing legal consequences of their writings. The intervention was designed to target the knowledge, attitudes, self-efficacy, and perceived social influence. Building upon IM steps one to three, a concept discharge protocol was developed that is relevant and feasible within current daily practice.

CONCLUSION

Intervention mapping provided a comprehensive framework to improve ICU discharge by guiding the development process of a theory- and empirically-based discharge protocol that is robust and useful in practice.

Identifying Information Resources for Patients in the Intensive Care Unit and Their Families

BACKGROUND

Providing information to patients in intensive care units and their families is challenging. Patients often are admitted unexpectedly and experience stress and uncertainty. One source of stress has been identified as unclear, uncoordinated, or inconsistent communication and information. Despite the need for information, no centrally located, easily accessible, standardized intensive care unit education content exists.

OBJECTIVE

To identify educational content for patients in the intensive care unit and their families across 4 different hospitals, develop a general content database, and organize the general content into a framework for education of patients and their families.

METHODS

Educational content for patients in the intensive care units of 4 participating hospitals was collected and a gap analysis was performed.

RESULTS

Key content format and categories were identified. Educational content was organized into an information pathway divided into 3 phases: intensive care unit arrival; understanding the intensive care unit and partnering in care; and intensive care unit transitions. The gap analysis revealed substantial variation in content format and categories.

CONCLUSIONS

Structuring a digital learning center using different stages of the patient’s stay in the intensive care unit and placing resources in the context of an information pathway can help coordinate education for these patients and their families, and creates a consistent communication guide for clinicians as well. The optimal digital format should be considered in designing the learning center.

Management of the chronically ventilated patient with a tracheostomy

Tracheostomy is the most common surgical procedure performed on critically ill patients. For those who survive their critical illnesses but remain ventilator-dependent, tracheostomy provides patients with a secure airway that frees the mouth for oral nutrition, enhances verbalized speech, and promotes generalized comfort. Avoiding complications from tracheostomy requires a skilled multi-disciplinary approach to ensure that the benefits outweigh the risks of the procedure.

Development and Effects of a Transition Nursing Program for Patients and Family Caregivers at a Neurological ICU in Korea

The purpose of this study was to develop a transition nursing program for patients and family caregivers in neurological intensive care units (ICUs) and to evaluate the effects of the program. A literature review, focus group interviews, analysis of medical records, confirmation of validity, and clinical applicability were used to develop the program, which was tested using a pre- and post-test quasi-experimental design. Participants were recruited in 2011. The experimental group (46 patients and their family caregivers) received the developed program before transferring from the neurological ICU to a ward, whereas the control group (48 patients and their family caregivers) received routine care. The results showed that patients and family caregivers in the experimental group had significantly higher transition readiness and satisfaction with transition nursing and lower transition anxiety and transition stress, and family caregivers in the experimental group had a significantly lower burden of caregiving.

Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial

OBJECTIVES

To evaluate the feasibility and effectiveness of an information pack, based on self-regulation theory, designed to support patients and their families immediately before, during and after discharge from an intensive care unit (ICU).

DESIGN AND SETTING

Prospective assessor-blinded pilot cluster randomised controlled trial (RCT; in conjunction with a questionnaire survey of trial participants' experience) in 2 ICUs in England.

PARTICIPANTS

Patients (+/- a family member) who had spent at least 72 h in an ICU, declared medically fit for discharge to a general ward.

RANDOMISATION

Cluster randomisation (by day of discharge decision) was used to allocate participants to 1 of 3 study groups.

INTERVENTION

A user-centred critical care discharge information pack (UCCDIP) containing 2 booklets; 1 for the patient (which included a personalised discharge summary) and 1 for the family, given prior to discharge to the ward.

PRIMARY OUTCOME

Psychological well-being measured using Hospital Anxiety and Depression Scores (HADS), assessed at 5±1 days postunit discharge and 28 days/hospital discharge. Statistical significance (p≤0.05) was determined using χ(2) and Kruskal-Wallis (H).

RESULTS

158 patients were allocated to: intervention (UCCDIP; n=51), control 1: ad hoc verbal information (n=59), control 2: booklet published by ICUsteps (n=48). There were no statistically significant differences in the primary outcome. The a priori enrolment goal was not reached and attrition was high. Using HADS as a primary outcome measure, an estimated sample size of 286 is required to power a definitive trial.

CONCLUSIONS

Findings from this pilot RCT provide important preliminary data regarding the circumstances under which an intervention based on the principles of UCCDIP could be effective, and the sample size required to demonstrate this.

TRIAL REGISTRATION NUMBER

Current Controlled Trials ISRCTN47262088; results.

The experiences of ICU patients during follow-up sessions--a qualitative study

OBJECTIVE

Evidence supports the recommendation for follow-up session(s) for patients after discharge from an intensive care unit (ICU). The aim of these follow-up sessions is to allow patients to express and discuss their experiences and problems following their time in an ICU. To optimise the knowledge gained from the follow-up session experience, it is necessary to describe how patients experience these sessions. The aim of this study was to describe how ICU-patients, experience a follow-up session.

DESIGN/SETTING

This study adopted a qualitative design utilising semi-structured interviews, and which examined the experiences of seven men and five women. Qualitative content analysis was utilised.

FINDINGS

The participants stated that the information gained from these sessions, which had previously seemed unclear to some of them, was, on the whole, now clarified and confirmed. A discernible difference was found between participants who were cared for on a general ward and those who were cared for on a rehabilitation ward and also were offered a meeting with a counsellor, following discharge their from the ICU. The findings also indicated that participants who were not offered psychosocial support showed a greater need for a follow-up session.

CONCLUSION

This study has highlighted the need for increasing collaboration between intensive care staff and staff in other units to provide support to this patient group in order to reduce their suffering post intensive care experience.

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.

Effectiveness of critical care discharge information in supporting early recovery from critical illness

Providing patients with information can alleviate or reduce relocation stress, but how best to provide information to patients being discharged from critical care units is unclear. This narrative critical review describes (1) the current evidence base on the use of discharge information for adult critical care patients and (2) the extent of involvement of service users in the design and evaluation of such information. Seven publications reported data from 121 patients, 252 relatives, and 33 nurses. Overall evidence was of low quality but use of individualized information was associated with beneficial physical effects for patients and increased knowledge and satisfaction for their relatives. Findings highlight the significant gaps in our knowledge and understanding. The consequences of such findings for the future development of information that meets service users' needs are discussed. Results should inform the design of future studies on this topic.

A trustful relationship--the importance for relatives to actively participate in the meeting with the physician

In previous research, no uniform picture emerged of the role of relatives in the meeting between an elderly patient and a physician. Knowledge about relatives' experiences of the meeting between an elderly patient and a physician will help healthcare practitioners better understand the role of relatives during the meeting and how practitioners can assist relatives in assuming their supporting role more efficiently. The purpose of this study is to explore experiences of relatives of meeting with the physician in a hospital setting when an elderly patient is discharged from hospital care to home care, in order to identify aspects that may facilitate relatives in taking up their role in a more efficient manner. This descriptive and exploratory study is based on 20 interviews with relatives. The result shows that the physician's communication style influences the meeting between the relative, the elderly patient, and the physician, and that this style is the result of power and interaction. A trustful relationship during the meeting between the relative and the physician can increase the relative's feeling of confidence with the healthcare organization and treatment of the elderly patient. The relative has an important supporting role in the care for the elderly family member, both in the hospital and the home setting. It is likely that the relative's value as a resource, for both the patient and the physician, increases as the relative experiences feelings of confidence in the meeting with the physician. It is therefore of value to increase our knowledge about the conditions and circumstances facilitating and/or hampering the meeting between the relative and the physician. The result stresses the importance of encouraging relatives to participate in the meeting. Physicians need more guidance and training in communication skills, respectful demeanor, and collaboration while meeting the relatives.

[The transition process from the intensive care unit to the ward: a review of the literature]

The optimum transition process from the ICU to the ward is key to avoiding the appearance of anxiety in the patient and family, increase of re-admissions in the ICU with the consequent increase in costs and jeopardization to the patient's safety.

OBJECTIVE

1) To identify, study and give a critical presentation of the existing evidence on how patients, families and nurses experience the transition from ICU to the ward; 2) to analyze the possible interventions available for the development of an optimum transition process.

METHODOLOGY

A review was made of the evidence available in the main databases. In addition, several journals specialized in Intensive Care were reviewed. Studies with a qualitative, quantitative or mixed approach and reviews on the subject with a systematic methodology or narrative reviews were included.

RESULTS

A total of 23 papers were selected for review, 10 of which were qualitative studies, 11 quantitative and two had combined methodology. «Transfer anxiety» was identified after the analysis of these articles as one of the recurring aspects. Discrepancies regarding who should take responsibility for the preparation of the transition process and when it should be performed were also found. In the literature reviewed, several interventions have been proposed to facilitate an optimal transition process such as developing information brochures, creating a profile of practicing nursing liaison between the ICU and the ward and ICU discharge report.

CONCLUSIONS

This review emphasizes the importance of taking into account the perspectives of patients, families and nurses to perform optimal planning of the transition of the patient from the ICU to the ward to ensure their safety.

Staff perception of patient discharge from ICU to ward-based care

BACKGROUND

The quality of information exchange between intensive care unit (ICU) and ward nurses, when patients are transferred out of intensive care, is important to the continuity of safe care.

AIM

This research aimed to explore nurses' experiences of the discharge process from ICU to the ward environment.

DESIGN

The study was conducted in a New Zealand Metropolitan hospital, using an exploratory descriptive design we adapted a questionnaire based on Whittaker and Ball's research on ICU patient handover.

METHOD

The questionnaires were then analysed using a descriptive thematic approach.

RESULTS

The response rate of 48% included 45 ICU and 47 ward nurses. Key findings were that the written and verbal communication needs differ dependent upon setting and the timing of a discharge. Timing of handover also requires negotiation.

CONCLUSIONS

Being able to negotiate the timing and nature of handover is important for nurses. In addition, standardized approaches to communication are believed to enhance patient safety.

RELEVANCE TO CLINICAL PRACTICE

Standardized handover, with content and processes that are mutually negotiated, is crucial to providing the safest environment for patients.

[Quality of life and satisfaction of family caregivers in palliative care - results of postmortem interviews with bereaved family members]

INTRODUCTION

Family caregivers play an important role in palliative care. However, the number of studies focussing on the quality of life of these family caregivers is limited. The current study evaluates quality of life and satisfaction with medical care in bereaved family members.

MATERIAL AND METHODS

Comparisons were made between (1) male vs. female family caregivers (N = 44) and (2) bereaved family caregivers vs. general population (EORTC QLQ-C30). Furthermore, the satisfaction of the family caregivers with medical care was assessed after the death of their relatives (ZUF HOPE). The interviews were conducted between six and eight weeks following the death of the palliative patients.

RESULTS

Regarding quality of life, bereaved family caregivers suffered from both reduced emotional functioning and general quality of life. Female caregivers had lower functional values and stronger symptoms of insomnia, fatigue and pain than male caregivers. Bereaved family caregivers had a lower quality of life than the general population. Retrospectively, family caregivers were very satisfied with most aspects of outpatient palliative care. The only aspect criticised by the bereaved family members was a lack of psycho-social support.

CONCLUSION

Family caregivers need stronger support in order to prevent burnout and to improve outpatient care. In this context, gender differences must also be considered.

Transition from neonatal intensive care unit to special care nurseries: experiences of parents and nurses

OBJECTIVES

To explore parents' and nurses' experiences with the transition of infants from the neonatal intensive care unit to a special care nursery.

DESIGN

Qualitative explorative study in two phases.

SETTING

Level IIID neonatal intensive care unit in a university hospital and special care nurseries (level II) in five community hospitals in the Netherlands.

PARTICIPANTS

Twenty-one pairs of parents and 18 critical care nurses.

METHODS AND MAIN RESULTS

Semistructured interviews were used. Thematic analysis and comparison of themes across participants were performed. Trust was a central theme for parents. Three subthemes, related to the chronological stages of transition, were identified: gaining trust; betrayal of trust; and rebuilding confidence. Trust was associated with five other themes: professional attitude; information management; coordination of transfer; different environments; and parent participation. Although nurses at an early stage repeatedly mentioned a possible transition to community hospitals, the actual announcement took many parents by surprise. Parents felt excluded during the actual transfer and most questioned its necessity. In the special care nursery, parents found it difficult to adjust to new routines and to gain trust in new caregivers, but eventually their worries dissolved. In contrast to neonatal intensive care unit nurses, special care nursery nurses quite understood the impact of transition on parents.

CONCLUSIONS

Both parents and nurses considered present transitional arrangements to be inadequate. Nurses should provide more effective discharge planning and transitional care. A positive labeling of the transition as a first step to home discharge for the newborn seems appropriate. Parents need to be better-informed and should be involved in the planning process.

Appreciation of a Child's Journey: Implementation of a Cardiac Action Research Project

The aim of this paper is to provide an overview of the phases of the action research process involved in developing, implementing, and evaluating the Heart Beads program. The aim of the project is to enrich the hospital experience of children with cardiac conditions. Heart Beads involves children receiving unique beads specific to each cardiac treatment, procedure or event in recognition of their experiences, and endurance. An action research approach, involving a partnership between clinicians and researchers and emphasising the involvement of patients and their families, was used to guide the Heart Beads program. The project followed the five phases of action research: identification, investigation, program development, implementation, and evaluation. Heart Beads began as a small project which continues to grow in popularity and significance with children at a tertiary paediatric hospital in Sydney, Australia. The program is now being implemented nationwide with the vision that all Australian children hospitalised with cardiac conditions can benefit from Heart Beads.

Development of an evidence-based information booklet to support parents of children without a diagnosis

The aim of this study was to develop an evidence-based psychosocial information booklet for parents of children without a specific diagnosis, many of whom are seen through the genetic clinic. A mixed methods approach was adopted involving four phases. The first two phases involving a systematic review and in-depth interviews are summarised briefly but reported in detail elsewhere. Phase 3 comprised: (1) a grey literature search to identify relevant literature and resources from other patient organizations; (2) drafting the booklet using themes identified through the previous phases; (3) piloting the booklet with eight professional and support group stakeholders and (4) piloting the booklet with 14 parents (from Phase 2) to ensure the information reflected their experiences. In Phase 4, we assessed satisfaction with the booklet through a questionnaire completed by 38 parents. The booklet was well accepted. The importance of providing the booklet at the beginning of the parental 'journey' was identified. We have developed an evidence-based information booklet to support parents via a rigorous mixed methods approach. This booklet meets a largely unmet psychosocial need and could be used in practice to support parents of children without a diagnosis.

Development and validation of a printed information brochure for families of chronically critically ill patients

OBJECTIVE

Families and other surrogate decisionmakers for chronically critically ill patients often lack information about patient prognosis or options for care. This study describes an approach to develop and validate a printed information brochure about chronic critical illness aimed at improving comprehension of the disease process and outcomes for patients' families and other surrogate decisionmakers.

DESIGN

Investigators reviewed existing literature to identify key domains of informational needs. Content of these domains was incorporated in a draft brochure that included graphics and a glossary of terms. Clinical sensibility, balance, and emotional sensitivity of the draft brochure were tested in a series of evaluations by cohorts of experienced clinicians (n = 49) and clinical content experts (n = 8) with revisions after each review.

SUBJECTS

Cognitive testing of the brochure was performed through interviews of ten representative family members of chronically critically ill patients with quantitative and qualitative analysis of responses.

MEASUREMENTS AND MAIN RESULTS

Clinical sensibility and balance were rated in the two most favorable categories on a five-point scale by more than two thirds of clinicians and content experts. After review, family members described the brochure as clear and readable and recommended that the brochure be delivered to family members by clinicians followed by a discussion of its contents. They indicated that the glossary was useful and recommended supplementation by additional lists of local resources. After reading the brochure, their prognostic estimates became more consistent with actual outcomes.

CONCLUSIONS

We have developed and validated a printed information brochure that may improve family comprehension of chronic critical illness and its outcomes. The structured process that is described can serve as a template for the development of other information aids for use with seriously ill populations.

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.

Barriers and benefits associated with nurses information seeking related to patient education needs on clinical nursing units

The purpose of this study was to answer the following two questions: What are clinical nurses’ rationales for their approaches to finding patient educational materials on the web? What are perceived barriers and benefits associated with the use of web-based information resources for patient education in the context of nursing clinical practice?

Over 179 individual data units were analyzed to understand clinical nurses’ rationales for their approaches to find patient educational materials on the web. Rationales were defined as those underlying catalysts or activators leading to an information need. Analyses found that the primary reasons why clinical nurses conducted web-based information searches included direct patient requests ( 9 requests), colleague requests (6 requests), building patient materials collections (4), patients’ family requests (3), routine teaching (1), personal development (1), or staff development (1). From these data, four broad themes emerged: professional reasons, personal reasons, technology reasons, and organization reasons for selecting information resources. Content analysis identified 306 individual data units representing either ‘benefits’ (178 units) or ‘barriers’ (128) to the nurses’ use of web resources for on-unit patient care. Inter-rater reliability was assessed and found to be excellent (r = 0.943 to 0.961). The primary themes that emerged as barriers to the used of web-based resources included: 1) time requirements to perform a search, 2) nurses’ experience and knowledge about the resources or required technology, 3) specific characteristics of individuals electronic information resources, and 4) organizational procedures and policies. Three primary themes that represented the benefits of using web-based resources were also identified: 1) past experiences and knowledge of a specific resource or the required technologies, 2) availability and accessibility on the unit, and 3) specific characteristics of individual information tool. In many cases, nurses commented on specific characteristics or features of favorite information resources. Favorite sites included a variety or reputable health care organizations that displayed context in text, audio, and/or video. In addition such sites were described as easy-to read and provided content related to patient-focused information or specific content such as toll free telephone contact numbers.

Information searching is the interaction between and among information users and computer-based information systems. Information seeking is becoming an important part of the knowledge work of nurses. Information seeking and searching intersects with the field of human computer interaction (HCI), which focuses on all aspects of human, and computer interactions. Users of an information system are understood as “actors” in situations, with a set of skills and shared practices based on work experiences with others. Designing better tools and developing information searching strategies that support, extend, and transform practices, begins by asking: Who are the users? What are the tasks? What is the interplay between the technology and the organization of the task? This study contributes fundamental data and information about the rationales nurses use in information seeking tasks. In addition it provides empirical evidences regarding barriers and benefits of information seeking in the context of patient education needs in inpatient clinical settings.

A systematic review of relocation stress following in-house transfer out of critical/intensive care units

EXECUTIVE SUMMARY

Objective The objective was to conduct a mixed methods systematic review to determine the occurrence and meaningfulness of relocation stress and the effectiveness of strategies for decreasing transfer anxiety in patients and their families upon transfer from an intensive care unit to a non-intensive care unit and to offer evidence-based recommendations for best practice.Inclusion criteria The review included quantitative and qualitative studies where the participants were adult intensive care patients, family members of adult intensive care patients, intensive care nurses caring for the adult critically ill patient, and ward/unit nurses receiving transfer patients from the ICU (intensive care unit). Studies examining the transfer experience for infants, children or psychiatric patients were excluded from this review.Search strategy The search strategy sought to find both published and unpublished studies and papers limited to the English language. An initial limited search of MEDLINE and CINAHL was undertaken followed by an analysis of text words contained in the title and abstract, and of index terms to describe the article. A second extensive search was then undertaken using identified key words and index terms.Methodological quality Each paper was assessed by two independent reviewers for quality prior to inclusion in the review using the Joanna Briggs Critical Appraisal Tools for experimental, cohort, descriptive, qualitative and expert text papers. Disagreements were discussed and resolved among the reviewers without needing to rely on a third reviewer.Data collection Information was extracted from each paper independently by two reviewers using the JBI extraction tools for quantitiative, qualitaitive and expert opinion papers and narrative table summaries were prepared.Data synthesis Data synthesis aimed to portray an accurate interpretation and synthesis of concepts arising from the experiences of patients and families transferring out of ICU and the nurses on the receiving and sending ends of the transfer.Results A total of 35 studies were identified and of those 25 were included in the review consisting of 15 qualitative studies, 9 quantitative studies and 1 clinical practice guideline. Qualitative papers were analyzed using JBI-QARI and involved categorizing findings and developing synthesized topics from the categories. Three syntheses were developed related to response to transfer, meaning of transfer, and strategies to facilitate successful transfer. Quantitative data could not be pooled and is presented in the narrative table.Conclusion For most, transfer to the general unit was not a traumatic or negative experience but viewed positively as a sign of recovery and sometimes the positive emotions coexisted with uncertainty or fear. The most negative experience was related to lack of observation and care on the general unit where nurses many times were unaware or unresponsive to functional deficits that the patients required assistance with. Patients were consequently challenged to do more for themselves and depending on their success or progress with independence resulted in growing confidence or frustration and embarrassment. The systems of care were not structured to effectively deal with the complex ICU transfer patient.Implications for practice Specific practice recommendations are made for pretransfer from ICU, system improvements to facilitate transfer and posttransfer care while on the general unit.Implications for research Additional research is needed to confirm the frequency of negative relocation stress, test efficacy of direct interventions and explore the meaning of transfer for family members.

[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.

Action research studies in the intensive care setting: a systematic review

OBJECTIVES

To review published studies using action research in the intensive care unit (ICU) in order to provide an intervention framework to improve clinical outcomes.

DESIGN

Systematic review.

METHODS

Searches of the electronic databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL); Scopus, Medline, Embase, PsycINFO, and the World Wide Web were undertaken using MeSH key words including: 'action research'; 'health care research', 'health services evaluation'; 'intensive care unit'. Reference lists of retrieved articles was also undertaken to identify further articles. All studies were reviewed by two authors using a critical appraisal tool.

RESULTS

The search strategy generated 195 articles. Only 21 studies projects were identified using action research in the ICU. The majority of studies were conducted in the United Kingdom. The participants in the action research studies ranged from 6 to 253. Predominately studies using action research involved nurses in collaboration with patients and family and other health care practitioners to address identified problems in the ICU.

CONCLUSIONS

Based on this review it appears that action research is a promising methodological approach to address clinical practice improvement in the ICU. Studies retrieved focussed primarily on process and formative evaluation but not on clinical outcomes. There is a need to incorporate outcome assessment in action research in the ICU to increase the framework of action research to improve clinical outcomes.

Written information that relatives of adult intensive care unit patients would like to receive--a comparison to published recommendations and opinion of staff members

OBJECTIVE

Information booklets have not been assessed by the families of intensive care unit (ICU) patients. This study explored the information that the relatives of adult ICU patients wanted to find in the information booklets.

DESIGN

Multicenter survey.

SETTING

Twenty-three French ICUs.

SUBJECTS

One close relative of each of 250 consecutive adult patients.

METHODS

Relatives were asked about the desirability of finding information on each of the 24 topics identified by ICU physicians and listed in guidelines as deserving inclusion in information booklets.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The 250 patients (61% men) had a mean age of 60 +/- 18 years and a mean Simplified Acute Physiology Score II of 48 +/- 19; 57% had chronic comorbidities and 41% were surgical patients. At least 72% of the relatives felt that booklets should discuss nosocomial infections, treatment-limitation decisions, access to medical information on the patient, access to medical records, and the meaning of medical terms. Overall, relatives wanted more information than that anticipated by ICU physicians, suggested in guidelines, or found in booklets. However, for at least one of the 24 topics, 38% of relatives indicated that fear or poor comprehension made them unwilling to receive written information. These relatives were younger and had fewer years of formal education than did the other relatives, and they were more likely to be visiting conscious unrestrained patients.

CONCLUSIONS

Opinions of relatives should be taken into account when designing ICU information booklets. Relatives want more information than that anticipated by physicians or suggested in guidelines, but the youngest or the less-educated ones may respond less favorably to written information.

Short- and long-term impact of critical illness on relatives: literature review

AIM

This paper is a report of a literature review undertaken to identify the short- and long-term impact of critical illness on relatives.

BACKGROUND

Patients in intensive care can experience physical and psychological consequences, and their relatives may also experience such effects. Although it is recognized that relatives have specific needs, it is not clear whether these needs are always met and whether further support is required, particularly after intensive care.

DATA SOURCES

The following databases were searched for the period 1950-2007: Medline, British Nursing Index and Archive, EMBASE, CINAHL, PsycINFO and EMB Reviews--Cochrane Central Register of Clinical Trials.

SEARCH METHODS

Search terms focused on adult relatives of critically ill adult patients during and after intensive care. Recurrent topics were categorized to structure the review, i.e. 'relatives needs', 'meeting relatives' needs', 'interventions', 'satisfaction', 'psychological outcomes' and 'coping'.

RESULTS

Studies have mainly identified relatives' immediate needs using the Critical Care Family Needs Inventory. There are few studies of interventions to meet relatives' needs and the short- and long-term effects of critical illness on relatives.

CONCLUSION

Despite widespread use of the Critical Care Family Needs Inventory, factors such as local or cultural differences may influence relatives' needs. Relatives may also have unidentified needs, and these needs should be explored. Limited research has been carried out into interventions to meet relatives' needs and the effects of critical illness on their well-being, yet some relatives may experience negative psychological consequences far beyond the acute phase of the illness.

Supporting families through discharge from PICU to the ward: the development and evaluation of a discharge information brochure for families

INTRODUCTION

Discharge from paediatric ICU and transfer to the ward can evoke fear and anxiety. Along with the introduction of the ICU liaison nurse role, the literature suggests that the provision of written information has the greatest potential to reduce transfer anxiety. This paper will discuss the issues associated with discharge from a paediatric ICU, the process of identifying the information needs of families, the development of a written brochure and evaluation of the brochure in practice.

RESULTS

Evaluation of the 'discharge from ICU' brochure found, 95% of parents believed the brochure was easy to read, understand and helpful in improving their understanding of what to expect on the ward. 95% also found it useful to have the transfer ward details written down prior to leaving the PICU. 85% agreed the brochure helped to answer their questions in relation to the transfer.

CONCLUSION

The introduction of a brochure explaining the process of discharge from ICU and what to expect on the wards received positive feedback from families. The brochure provides families with generic information regarding ICU transfer, however, it is important for the ICU liaison nurse to promote discussion and tailor the information for the particular experiences and needs of each patient and family situation.

Facilitating transitions. Nursing support for parents during the transfer of preterm infants between neonatal nurseries

AIMS AND OBJECTIVES

Transfers between neonatal units are significant transitional experiences for parents of preterm infants. The study aimed to investigate practices that nurses identify as supportive to parents during preterm infants' transfers. It explored the influence of organisational context on practice and what strategies nurses perceive would help them to provide supportive care.

BACKGROUND

Parents' experiences of neonatal nurseries, their stressors and needs have been well documented. The powerful position of nurses in influencing parenting experience is also recognised. However, nurses' understanding of the transfer process, their roles in supporting parents through this and the organisational context influencing practice have not been explored.

DESIGN AND METHODS

A focus group design was used composed of registered nurses from two neonatal units who met for a series of group interviews. Eleven registered nurses participated. They explored and critiqued their current practices and then established aims and strategies for practice development. A qualitative content analysis was conducted.

RESULTS

Participants identified validation, empowerment and communication as critical to effective practice. They identified a range of organisational dynamics, from logistical issues to nursing authority and scope of practice, as these influenced practice. They presented strategies for practice development, including staff education and the development of nurse practitioner roles.

RELEVANCE TO CLINICAL PRACTICE

This study explores nurses' understanding and insights into transitions for parents of preterm infants. It shows a congruence between nurses' perceptions of parents' experiences and needs and those reported by parents in previous studies. It articulates the way nurses practice in response to these perceptions, and the manner in which organisational dynamics influence their ability to facilitate transitions. The need to invest in transitions and invest in nurses to facilitate transitions is proposed, ultimately by increasing their clinical authority and autonomy.

Nursing support for family members of critically ill adults

Researchers have identified the needs of family members of critically ill adults, explored their experiences, and investigated interventions. To address a gap in the theoretical knowledge about how nurses help these individuals, the authors developed a grounded theory of nursing support from the perspective of family members. Results indicated that family members were initiated into a cycle of Work to meet perceived responsibilities to Get Through the experience. Supportive nurses engaged in the process of Lightening Our Load to mitigate the negative effects of the critical care experience on family members by Engaging With Us, Sustaining Us, and Disengaging From Us. No previous research has yet identified the Work of these family members, the steps they take to gain nurses' respect, and the significance to them of nurses' Welcoming us and Saying goodbye. This theory extends the understanding of nursing support beyond current knowledge of family needs, caring, comfort, supportive care, and social support.

Leaving critical care: facilitating a smooth transition

Patient transfers from one area to another occur frequently within the inpatient healthcare environment. During transfers, nurses pass on information about patients to one another in a variety of ways. This article discusses the types of patient transfers, the problems that can occur throughout the transfer process, and strategies to decrease the identified problems. The perspectives of both the nursing staff and patients/families illustrate concerns related to patient transfers. The most important aspect of the patient transfer is systematically communicating necessary information to the receiving nurse in such a way that patient safety is not compromised and continuity of care is enhanced.

Dimensions of caring: psychometric evaluation of the caring assessment tool

The increase in relationship-centered professional practice models has expanded the interest in the measurement of caring. Using a cross-sectional descriptive study of 557 adults from 5 acute care institutions, a factor analysis and reliability statistics were used to revise the Caring Assessment Tool. Eight independent factors (mutual problem solving, attentive reassurance, human respect, encouraging manner, appreciation of unique meanings, healing environment, affiliation needs, and basic human needs) explained 62.6% of the variance in caring. The findings provide insight into patients' assessment of caring in nursing and offer a baseline evaluation of the psychometric properties of the Caring Assessment Tool.

Methodological aspects of rigor in qualitative nursing research on families involved in intensive care units: a literature review

Rigor has important ramifications for the entire qualitative research process. The aim of this study was to evaluate aspects of methodological congruence by focusing on four dimensions of rigor in qualitative nursing research related to the presence of patients' family members in the intensive care unit. Eight research papers covering the years 1990-2004 were analyzed by means of one of Burns and Grove's standards, methodological congruence, for critique and consistency. The results show that there are varying degrees of focus on procedural rigor, such as limitations and bias. Ethical rigor is described clearly in some papers, while others lack descriptions of confidentiality and the voluntary nature of participation. However, all papers contain descriptions of qualitative data analysis. In conclusion, there were strengths in procedural rigor and auditability, but also some limitations in the identification of theoretical development and the scientific tradition on which the article is based.

The process of developing audiovisual patient information: challenges and opportunities

AIM

The aim of this project was to produce audiovisual patient information, which was user friendly and fit for purpose. The purpose of the audiovisual patient information is to inform patients about randomized controlled trials, as a supplement to their trial-specific written information sheet.

BACKGROUND

Audiovisual patient information is known to be an effective way of informing patients about treatment. User involvement is also recognized as being important in the development of service provision. The aim of this paper is (i) to describe and discuss the process of developing the audiovisual patient information and (ii) to highlight the challenges and opportunities, thereby identifying implications for practice. A future study will test the effectiveness of the audiovisual patient information in the cancer clinical trial setting.

METHODS

An advisory group was set up to oversee the project and provide guidance in relation to information content, level and delivery. An expert panel of two patients provided additional guidance and a dedicated operational team dealt with the logistics of the project including: ethics; finance; scriptwriting; filming; editing and intellectual property rights.

RESULTS

Challenges included the limitations of filming in a busy clinical environment, restricted technical and financial resources, ethical needs and issues around copyright. There were, however, substantial opportunities that included utilizing creative skills, meaningfully involving patients, teamworking and mutual appreciation of clinical, multidisciplinary and technical expertise.

CONCLUSION

Developing audiovisual patient information is an important area for nurses to be involved with. However, this must be performed within the context of the multiprofessional team. Teamworking, including patient involvement, is crucial as a wide variety of expertise is required.

RELEVANCE TO CLINICAL PRACTICE

Many aspects of the process are transferable and will provide information and guidance for nurses, regardless of specialty, considering developing this format of patient information.

The perspective of families of the critically ill patient: their needs

PURPOSE OF REVIEW

An appreciation of a family's difficult experience in dealing with their critically ill loved ones has created the concept of 'family-centered care'. The purpose of this paper is to review the literature on the needs of the family during their intensive care unit experience.

RECENT FINDINGS

Families consistently highlight three major issues that they deem could be improved from their perspective. Increased information about their loved ones, proximity to the patient and a more flexible visiting policy stand out as relevant issues to families.

SUMMARY

Medical staff and administrators should recognize that families of critically ill patients have particular needs that help them cope with having their loved ones in an intensive care unit. Simple changes in philosophy and policy would greatly decrease the anxiety these families experience.

Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004–2005

OBJECTIVE

To develop clinical practice guidelines for the support of the patient and family in the adult, pediatric, or neonatal patient-centered ICU.

PARTICIPANTS

A multidisciplinary task force of experts in critical care practice was convened from the membership of the American College of Critical Care Medicine (ACCM) and the Society of Critical Care Medicine (SCCM) to include representation from adult, pediatric, and neonatal intensive care units.

EVIDENCE

The task force members reviewed the published literature. The Cochrane library, Cinahl, and MedLine were queried for articles published between 1980 and 2003. Studies were scored according to Cochrane methodology. Where evidence did not exist or was of a low level, consensus was derived from expert opinion.

CONSENSUS PROCESS

The topic was divided into subheadings: decision making, family coping, staff stress related to family interactions, cultural support, spiritual/religious support, family visitation, family presence on rounds, family presence at resuscitation, family environment of care, and palliative care. Each section was led by one task force member. Each section draft was reviewed by the group and debated until consensus was achieved. The draft document was reviewed by a committee of the Board of Regents of the ACCM. After steering committee approval, the draft was approved by the SCCM Council and was again subjected to peer review by this journal.

CONCLUSIONS

More than 300 related studies were reviewed. However, the level of evidence in most cases is at Cochrane level 4 or 5, indicating the need for further research. Forty-three recommendations are presented that include, but are not limited to, endorsement of a shared decision-making model, early and repeated care conferencing to reduce family stress and improve consistency in communication, honoring culturally appropriate requests for truth-telling and informed refusal, spiritual support, staff education and debriefing to minimize the impact of family interactions on staff health, family presence at both rounds and resuscitation, open flexible visitation, way-finding and family-friendly signage, and family support before, during, and after a death.

Information booklets to patients' family and relatives. Survey of practice in a sample of 59 intensive care units, in France

OBJECTIVE(S)

To assess the content of the intensive care unit (ICU) information booklet delivered to patient families, and that of the general information booklet of the hospital in a sample of intensive care, in France.

STUDY DESIGN

Survey.

METHODS

A sample of 105 ICU was obtained at random from a national database. A survey form was sent to each ICU medical director. The ICU information booklet, that one from the hospital and the corresponding questionnaire of each participating ICU have been studied to assess the percentage of information items present which matched the recommendations of at least one of three different professional guidelines.

RESULTS

Fifty-nine ICU answered. We observed a significant (P<0.01) heterogeneity by the kind ICU considered (general, medical, or surgical). The percentage of information items matching guidelines remained low (median: 41%) even if higher (P<10(-3)) than the percentage of items not matching guidelines (median: 6%). Among a panel of items we considered as important, we observed a significant discrepancy (P<10(-3)) between a low citation rate in ICU booklets (median: 14%) and the opinion of doctors who judged it should included in booklets (median: 68%).

CONCLUSION

Guidelines in terms of patient and family information in ICU seem to have a mild impact on the information booklets which are also very different among the types of ICU. There is a gap between what doctors judge to be included in booklets and what they effectively write in these documents.

Supportive care needs of people with brain tumours and their carers

GOALS OF WORK

The diagnosis and treatment of a brain tumour may result in long-term changes in a patient's functional and social abilities and/or in a greatly reduced life span. A qualitative investigation was conducted to examine the supportive care needs of patients with brain tumour and their carers.

MATERIALS AND METHODS

Overall, 18 patients and 18 carers participated in focus groups or telephone interviews, following a structured interview guide to elicit supportive care services of importance to these patients and carers.

MAIN RESULTS

Six major themes were identified using the framework analysis method, including needs for information and coping with uncertainty, practical support, support to return to pretreatment responsibilities or prepare for long-term care, support to deal with social isolation and organize respite care, support to overcome stigma/discrimination and support to discuss potentially reduced life expectancy.

CONCLUSIONS

Five recommendations to improve service delivery include: assignment of a dedicated member of the care team or case manager; proactive dissemination of information, education and psychosocial support; access to objective assessment of neuropsychological functioning; facilitating easier access to welfare payments; and services facilitating communication about difficult illness-related topics. Provision of services along these recommendations could improve supportive care of brain tumour patients and their carers.

Improving transfer from the intensive care unit: The development, implementation and evaluation of a brochure based on Knowles' Adult Learning Theory

This paper describes the development, implementation and evaluation of a transfer brochure for family members of patients in an intensive care unit (ICU) to improve patient transfer to a general ward. When family members fail to understand information, they respond in ways that affect patient recovery. The brochure was designed within Knowles' Adult Learning Theory framework and developed using a multidisciplinary team. A mixed design was used to collect data from families and nurses. Results indicate that the brochure helped nurses to address the individual family's issues during transfer from ICU. Furthermore, 95% of nurses (n = 33) recommended its introduction for all future transfers. Family members (n = 82) who received the brochure as part of their transfer were significantly more satisfied with all aspects of transfer than those who experienced ad hoc transfer methods (n = 80). These results provide strong support for Knowles' Adult Learning Theory as an educational foundation for adult learning.