Background
Methods
Study design
Study population
Data collection
Composed vignettes of the roundtable meetings with the nursing staffs | ||
# | Vignette elements | Reference |
1 | Reduction of non-essential monitoring and nursing care in ICU prior to discharge. | |
Informal preparation of the patient prior to discharge; tailored discussion of decreased monitoring, less staff, reassurance of worries. | ||
Consultative ICU nurse, currently providing one or more consecutive evaluations of the former ICU patient, and signed off when deemed stable. | ||
2 | New folder with information about the differences between ICU and wards, topics covered by the nurses in semi-structured conversation (checklist). Reassurance of worries. | |
Relatives visiting the general ward prior to discharge. | [41] | |
A personalized lay summary of the patients’ ICU stay. | ||
3 | Distribute the booklet ´Your recovery after ICU´ to the patient or their relatives. | |
Acquaintance visit of the patient to the ward prior to discharge. | [41] | |
4 | Use of diaries; this means an active involvement of patients and relatives in identifying and meeting their own needs, and offering opportunities for reflection. | |
Adapted handover with emotional and psychosocial situation described, supported in electronic patient file. | [45] | |
5 | Ward nurse visiting the patient in the ICU. | |
Semi-structured interview with former ICU patients and relatives | ||
# | Questions | |
1 | What was important to you prior to discharge from the ICU? | |
2 | What was important during discharge and the introduction to the new ward? | |
3 | How did you feel in the first days after discharge from the ICU? | |
4 | How did you feel regarding your safety in the ICU and the general ward? | |
5 | Did you miss specific issues in the care after you left the ICU, and if so, please explain these? | |
6 | What would you like to improve, assuming an ideal situation? |
Data analysis
Results
Step 1: Problem analysis
Main theme | Units of meaning |
---|---|
Minimize or drop monitoring | “It would have been reassuring if monitoring was paused while my husband was still in the ICU.” (ID#r2) “If you don’t monitor the arterial catheter, then it must be removed. But it isn’t very comfortable for the patient if you need to have blood samples thereafter.” (ICU nurse) “If I expect discharge, then I examine the last Ästrup and correct what is necessary. Then the arterial line is really taken out.” (ICU nurse) “I think it is obligatory to monitor the patient during ICU admission. Therefore, I won’t drop down this because of safety reasons.” (ICU nurse) |
Providing information | “It is important to inform the patient that discharge is a transition from continuous monitoring to occasional rounds and that the situation is stable enough to allow for this downsizing.” (ID#r2) “I always tell them [the ICU patients] that it is different in the general ward. A general ward nurse has to look after more than two patients, but it is suitable and safe care. Not everybody prepares the patient, I know.” (ICU nurse) “It should occur both in the ICU and in the general ward. Our care doesn’t end at the doors; we should provide structured information about what is to be expected after discharge. However, they [the general ward nurses] should be more prepared.” (ICU nurse) “A structured checklist can be a good tool to use.” (ICU nurse, general ward nurse) “The information should be provided both orally and in written form for reading at their own pace and on their own time.” (general ward nurse) “Without any monitoring, it took a little time to get used to. But more importantly, they had no idea! In the beginning, I was on Mars, and I came to Pluto thereafter.” (ID#p1) “There is little knowledge among professionals. I would have greatly benefited from an informational brochure. I was very anxious about my condition, but I couldn’t talk to anyone.” (ID#p1) “I’ve encountered so much ignorance, and I felt that I was not taken seriously. Providing more information and good communication, even a five-minute talk, could really make a difference.” (ID#r1) |
Acquaintance visit | “I would have appreciated meeting some of the professionals of the next ward, just to become a little more familiar with them. The reassurance of a nurse coming to the ICU would have helped me.” (ID#p1) “Involving the relatives is a good idea if it is optional. They must not feel obliged to be present during the transition to the ward.” (ICU nurse) “I think it is a great deal but that it isn’t reality. An acquaintance visit is too impractical for all of us, even if only relatives are involved. If they need to be here during transition, the general ward should provide this hospitality at the time, whereas in the ICU, we don’t know specific details of the visiting hours in all the different follow-up wards.” (ICU nurse) “That isn’t ideal; for example, even if I come in today, I might not be working tomorrow, so it isn’t very useful then.” (general ward nurse) |
Time and logistical constraints | “Hurriedly and focusing on speed, the communication was very stormy. If there had been more time and opportunity to ask questions, then we would have been less stressed in the next ward.” (ID#r1) “It goes far too quickly. I was just awoken and immediately discharged. There was barely time to prepare. I was also too ´groggy´ to listen to the information at that time.” (ID#p4) “If we could work one-on-one, then we would have enough time for emotional support.” (general ward nurse, ICU nurse) “Oh no, that is really absurd. There is no time, and it isn’t safe for the patient to have an acquaintance visit to the general ward prior to discharge. But if the relatives would like to be involved and go there, that would be useful.” (ICU nurse) “I really haven’t the time to visit the patient in the ICU prior to admission to our ward!”. (general ward nurse) |
Writing a lay summary | “I had no idea what had happened, why I felt like this. I wished someone had told me, wrote down a timeline, explained what I had experienced in understandable words.” (ID#p4) “Writing a lay summary, I think, it is too subjective. I wouldn’t know how to do that, how to go beyond ´patient slept well, no pain´ and still convey medical information. What is meaningful and not legally disputable or wrong? For example, we judge delirious behavior differently than the relatives do. That is difficult to describe.” (ICU nurse) “On my first day of work, I’m too unfamiliar with the patient to that.” (ICU nurse) “That will certainly help the patient and their relatives.” (general ward nurse) |
Consultative ICU nurse | “I never discussed my ICU experiences at the time. I missed that enormously, and I think it would have helped me to process my feelings, my insecurity, and my anxious thoughts.” (ID#p4) “I have noticed that the patients appreciate that you’ve come. Some general attention provides confidence in their situation.” (ICU nurse) “What I see is that we often just go by to check the physical condition. The emotional processing has not yet begun on the first day after discharge. Only after four or five days does the patient start thinking about what happened. So, that is not applicable to the consultative ICU service.” (ICU nurse) “It would be nice if the ICU nurse could come for a longer time period to talk to the patient about their experiences.” (general ward nurse) |
Liaison nurse | “What I’ve missed is the feeling of enough knowledge in the general ward about the impact of an ICU admission, the understanding of my fears and anxieties. It would have been nice to talk about my emotions with an independent professional with profound knowledge of the ICU.” (ID#p2) “They [the management team] should hire a special professional just to support the relatives. This is very useful and valuable work. A lot of benefit can be gained by providing deeper emotional support for the ICU patient and their relatives.” (ICU nurse) “All this should be done by a nurse without direct patient care that day. Maybe a few dedicated nurses could work on this emotional support task.” (ICU nurse) |
“The transition from the ICU into the high care was quite scary. My mother no longer needed full monitoring at her bedside, however, I didn’t sleep that night because of this removal. The transition to the general ward was even worse and I felt very vulnerable, really thrown into the deep end. I wished we were told about the next phase, why discharge at that time, what is the difference between ICU and the general ward, and how is the usual work flow.”
Roundtable | Setting | No. of participants | Female participants (%) | Discussed vignette |
---|---|---|---|---|
1 | ICU | 18 | 67 | 1, 2, 3 |
2 | ICU | 16 | 63 | 1, 2, 3 |
3 | ICU | 8 | 75 | 1, 2, 3 |
4 | Neurology ward | 4 | 100 | 2, 4, 5 |
5 | Surgery ward | 4 | 100 | 2, 4, 5 |
6 | Neurosurgery ward | 5 | 80 | 2, 4, 5 |
7 | Surgery ward | 6 | 83 | 2, 4, 5 |
Step 2: Identify intervention outcomes, performance objectives and change objectives
Performance objectives | |
---|---|
Person-centered care | |
1a | Tailor aftercare to the person’s needs and preferences |
1b | Present a hospitable attitude |
1c | Listen to the concerns of the patients and their relatives |
1d | Involve the relatives in the discharge process |
Integrated care | |
2a | Improve discharge-planning in the ICU |
2b | Coordinate non-technical aspects of patient care between ICU and general ward nurses |
2c | Provide information on the Post Intensive Care Syndrome to the patient |
Discharge communication | |
3a | Prepare the ICU patient and/or relatives for discharge according the protocol |
3b | Use both oral and written material in preparation for discharge |
3c | Use clear language in information exchange to patients, relatives and general ward nurses |
Step 3: Select theory-based methods and practical applications
Determinant | Method (Related theory and reference) | Description (In Bartholomew et al. [30] | Examples of practical applications |
---|---|---|---|
Basic conditions | Participation (Diffusion of Innovations Theory [52]) | Assuring high level engagement of the participants´ group in problem solving, decision making, and change activities. | Active involvement of three groups of stakeholders, using feedback of all participants, development of protocol through project group members. |
Guiding individuals and environmental agents toward the adoption of an idea, attitude, or action by using arguments or other means. | The discharge protocol is relevant, practical, and not too discrepant from the nurses’ beliefs and values. | ||
Knowledge | Knowledge transfer (Elaboration Likelihood Method [51]) | Stimulating the learner to add meaning to the information that is processed. | Bridge the nurses’ knowledge gap in PICS by providing information in written material, oral explanations, and digital means. |
Active learning (Social cognitive Theory [67]) | Encouraging learning from goal-driven and activity-based experience. Need for time and information. | Group discussion on optimal discharge actions from ICU. Teacher stimulates nurses to ask questions and think of preventing PICS. | |
Attitude | Implementation intention (Theories of Goal Directed Behavior [68]) | Prompting making if-then plans that link situational cues with responses that are effective in attaining goals or desired outcomes. | If the intended discharge becomes final, then the ICU nurse calls the contact person, starts oral conversation with the patient according to the checklist, and provides written material on PICS. |
Discussion and elaboration (Elaboration Likelihood Model [51]) | Listening to arguments and opinions to ensure that the correct mental schemas are activated. | Organize team discussions on facilitators and barriers with the discharge protocol. | |
Self-efficacy | Skill training (Social Cognitive Theory [67]) | Learning by practicing the needed skills. | Nurses feel satisfied and competent by practicing the discharge talk with an ICU patient. |
Feedback | Giving information to nurses regarding the extent to which they are accomplishing learning. | Showing results of a pretest and posttest on PCIS. | |
Perceived social influence | Combines caring, trust, openness, and acceptance with support for behavioral change, positive support is available in the environment. | Champions and nursing leaders discuss and promote performing the discharge protocol. Teachers help nurses to assimilate knowledge on PICS. | |
Increasing stakeholder influence (Stakeholder theory [71]) | Increase stakeholder power, legitimacy, and urgency, often by forming coalitions and using community development and social action to change an organization’s policies. | Storytelling by experts from Foundation FCIC. Patients included in focus group discussions on relevant topics |