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Providing continuity of care for patients transferred from ICU

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Susan Haines, BSc (Hons), RN.

Practice Development Nurse - Critical Care, Nottingham City Hospital NHS Trust, when this paper was written. She is now Local RCN Leadership Facilitator

Nurses are currently working in a health service where there are increasingly fluid boundaries between critical and acute care areas (Gibson, 1997). Highly dependent patients with complex treatments are being cared for in ward areas. Recent government recommendations identify the need for consistent standards of care for critically ill patients irrespective of where they are located within a trust. Patients transferred from intensive care units (ICUs) may be highly dependent both physically and psychologically. The impact on ward nurses is an under-researched area which merits investigation.

Nurses are currently working in a health service where there are increasingly fluid boundaries between critical and acute care areas (Gibson, 1997). Highly dependent patients with complex treatments are being cared for in ward areas. Recent government recommendations identify the need for consistent standards of care for critically ill patients irrespective of where they are located within a trust. Patients transferred from intensive care units (ICUs) may be highly dependent both physically and psychologically. The impact on ward nurses is an under-researched area which merits investigation.

A national shortage of ICU and high-dependency beds, with varying admission and discharge criteria, result in inconsistencies in quality and continuity of care for patients transferred to ward areas (NHS Executive, 1996; Edbrooke et al, 1997; Audit Commission, 1999). Complex treatments previously undertaken only within critical care environments are now being seen in some ward areas, and the dependency levels of patients are rising. The Government has set out a five-year plan for the development of a 'comprehensive critical care' service across the NHS (DoH, 2000a).

Caring for increasing numbers of patients with complex problems can cause stress for ward nursing staff already facing work overload (Place and Cornock, 1997; Wheeler, 1998). Issues relating to the support of nurses working under increasing stress and the current crisis of recruitment and retention have been debated within the nursing press and literature over recent years (Kennedy and Grey, 1997; Webley-Brown, 1997; Morris, 1998; Gulland, 1998, DoH, 2000b; 2000c).

Difficulties described by patients and relatives on transfer from ICU following a period of critical illness are well-documented (Turnock, 1997; Dyer, 1995a; 1995b). Research studies continue to highlight physical and psychological problems for this patient group (Rustom and Daly, 1993; Jones and O'Donnell, 1994; Jones et al, 1994; Sawdon et al, 1995; Waldmann and Gaine, 1996; Hall-Smith et al, 1997; Waldmann, 1998; Odell, 2000). In spite of the difficulties observed in practice, there is minimal literature available considering the perspective of the ward staff caring for these patients following transfer from intensive care.

Aims and method
The aim of the pilot study was to identify the difficulties faced by ward staff caring for patients transferred from intensive care.

An exploratory, qualitative design was developed using semi-structured interviews in order to identify specific difficulties that ward staff encounter.

Sampling technique - A purposive sample was used composed of one male and four female registered nurses from ward areas taking the most patient transfers from a general adult intensive care unit over an 18-month period (March 1997 to August 1998). Length of tenure ranged from 18 months to 14 years. Participants worked internal rotation on night duty to allow for a 24-hour perspective. The limitations of a purposive sample are acknowledged, in that it 'provides no external, objective method for assessing the typicalness of the selected subjects' (Polit and Hungler, 1995). However, this method of sampling is frequently used in qualitative research to extend knowledge by providing rich data (Reed and Proctor, 1996).

A database (Riyadh ICU programme) was developed (Chang, 1992) and used to obtain accurate patient data. Thirty-five ward areas within the trust received patients transferred from intensive care. The four non-critical care areas receiving the highest number of transfers, ranging from 29 to 62 patients, were identified. These were two medical and two surgical areas. By identifying areas that took high numbers of transfers, the researcher aimed to locate participants who could best inform the study. A small sample size is sufficient when participants have in-depth knowledge of the subject under study (Holloway, 1991; Morse and Fields, 1996).

Senior nurse managers and ward managers of identified areas were contacted. A minimum of one participant from each area was requested to fit within the time constraints of the study.

There is a potential for selection bias when using a purposive sample and the internal validity of the study could be effected (Polit and Hungler, 1995). The researcher had no control over the methods used for identification of participants from each area by the ward managers.

Data collection tool - A flexible framework of questions was formulated, aiming not to limit or focus the interviews towards the bias of the researcher. Questions were devised around issues identified by patients and families, concerning the difficulties experienced on transfer to non-critical care areas (Jones et al, 1994; Cutler and Garner, 1995; Waldmann and Gaine, 1996). The use of open-ended questions aimed to allow participants to reflect on the broad issues in light of their personal experiences, enabling a more holistic examination of the subject.

By pre-testing interview questions on a colleague, any lack of clarity in the structure of the interview or format of questions could be identified, and the validity of the tool assessed in light of the aims of the study (Morse and Fields, 1996; Bell, 1991). Following pre-testing, the questions were re-ordered to improve the continuity and structure of the interview. A trial interview was then undertaken with a ward nurse.

Data analysis - Content analysis, based on Burnard's method of analysing interview transcripts in qualitative research, was chosen for the purpose of this study (Burnard, 1991). The use of two colleagues (inter-raters) to independently review the transcripts and generate their own categories aimed to validate the coding method and enhance reliability, reducing the risk of researcher bias. Categories identified were then returned to the participants for validation.

Results and discussion
The aim of the study was to identify the difficulties faced by ward staff caring for patients transferred from ICU. Analysis of the data revealed difficulties that could be grouped under four main categories:

- Staff stress

- Patient-nurse relationship

- Knowledge and skills

- Psychological difficulties for patients and families.

The improvements to care suggested by the deficiencies noted during patient transfer from ICU to a ward area, as revealed by the data, are described in Figure 1.

Staff stress - The most frequently identified difficulties from the data were categorised under the heading of staff stress. All participants referred to anxiety, stress or fear experienced by ward staff when receiving a patient from intensive care. Staff felt uncertain as to what to expect, describing patients as highly dependent and sometimes unstable. This is congruent with the findings of Whittaker and Ball (2000). One nurse said: 'Receiving these people back is often quite daunting.'

Lack of control - A lack of control over the transfer process and a feeling of inevitability were identified as stressful by four participants. Existing literature does not address these aspects of a transfer as studies focus on the perspective of the patient or ICU staff. Jones and O'Donnell (1994) highlighted the need for the patient to feel in control in order to cope successfully with stressful situations such as a transfer. This sense of control is also important for ward staff when faced with the transfer of a patient. Participants clearly describe feelings of loss of control, a central influence in an individual's experience of stress (Lazarus, 1966). Involvement in decisions and control over workload have been identified as beneficial in reducing stress (Cox, 1990; Warr, 1992). One nurse commented: 'Whether you're busy or not busy the patient's coming, you've got to do it.'

The one participant who did not express lack of control did describe feeling pressurised to take patient transfers.

Nursing needs and workload pressures - All participants identified the time and experience necessary to accept a patient transfer and care for the patient with intensive nursing needs. One respondent said 'They're bed bound, they've got... catheters, CVPs and whatever and they come back needing you and by the time you've sorted them out it's more or less time to repeat the process.'

However, this intensive nursing care was not viewed solely as a negative stressor for staff. Two participants directly referred to enjoying looking after this patient group. Interest in caring for patients with varied needs was the rationale given and the same participants expressed interest in gaining experience in ICU. Stress arose when trying to provide care for the rest of their allocated patients. This may impact on quality of care delivered to other patients in the ward and is another difficulty that was not raised in previous studies.

Patient-nurse relationships - Two main issues were raised in the area of staff-patient relationships.

Issues affecting continuity of care - During the course of the interview all participants were asked what they felt could be done to enhance the continuity of care of these patients. Patients were not prepared for the change in environment or the differences in the ratio of staff to patients.

Three participants suggested that a ward nurse should visit the ICU to see the patient before transfer, so that the patient and relatives could recognise the nurse after transfer. This has been recommended in previous literature (Cutler and Garner, 1995; Saarmann, 1993; Whittaker and Ball, 2000).

Follow-up for patients and relatives - All participants said that they telephoned ICU for advice when faced with difficulties, finding the staff helpful. Follow-up for patients and relatives was considered important and all participants felt that this was beneficial. This was thought to be due to the special bond that the patient can develop with the ICU nurse who has been caring for him or her on a one-to-one basis.

One participant said: 'Because you do bond with somebody when you've been very poorly. I think that would be a good idea once they're settled on the ward, that somebody from the unit still comes. They're there to support us, they're there to support the patients and the family.'

Current government service developments in critical care advocate role developments such as critical care outreach teams and follow-up clinics for patients following discharge from ICU (DoH, 2000c).

Knowledge and skills - The importance of developing the skills and knowledge of health-care staff so that they can care for this group of patients effectively is recognised at government level. 'Lifelong learning' to enhance continuity and quality of patient care is proposed (DoH, 1997). Competency-based high-dependency skills development programmes for nurses in non-critical care areas are now being delivered in many trusts. These provide an opportunity for nurses to reflect on patients they have cared for with high-dependency needs and practise clinical skills in a safe, non-threatening environment (Haines and Coad, 2001).

The knowledge base and clinical skills required to care for these patients were identified by all participants. Experienced staff were allocated to look after transfers from ICU when available. Two participants mentioned that it was their experience that enabled them to make a professional judgement on whether or not to accept the patient back into the ward. This was thought to be a potential problem when more junior staff were on duty because they may not have the experience and knowledge to make an informed decision. Four participants mentioned concerns for junior staff in relation to clinical skills. One nurse said: 'If you (are inexperienced) then how are you able to say yes or no? I mean there's no sort of set criteria as to what we're allowed on the ward and not allowed is there? It's just sort of what seems to be sensible or safe.'

Identifying clinical skills - All five participants mentioned caring for patients with a tracheostomy. Only one participant said that tracheostomies did not cause difficulties within their clinical area, as staff frequently cared for them and all were competent. A wider sample group from this area would be required to identify if this was representative of all staff.

One nurse commented: 'As you see things more and more you become confident and more competent don't you? You're not so scared of it.'

Patients were described as tending to require close observation using more equipment. Two participants mentioned that specialist respiratory support such as high-flow oxygen therapy and continuous positive airway pressure circuits caused difficulties. These critical-care therapies are becoming more frequently required and there is a need for the ongoing development of ward nurses (Place and Cornock, 1997; Gibson, 1997). This should be accompanied by risk assessment of clinical areas to ensure an appropriate environment and staffing before more complex respiratory treatment is offered.

The use of medical equipment - All participants identified that obtaining or using appropriate medical equipment caused difficulties for staff.

Nurses have identified feeling unprofessional and scared if they cannot operate medical equipment with expertise (Wichowski and Kubsch, 1995). Intravenous giving sets and pumps were the main pieces of equipment that had to be located and/or borrowed, sometimes with difficulty, before transfer. Using equipment with which staff are unfamiliar increases the risk of errors. The Medical Devices Agency has reported a significant risk of adverse incidents associated with the use of infusion devices. Training and competency assessment of nurses has been identified as vital (Morling, 1998; Quinn, 2000). The NHS Controls Assurance Standards for medical devices requires that all staff have evidence of competency before using medical equipment (NHS Executive, 2000).

Psychological issues for patients and families
All participants described the problems of providing psychological support to these patients. They described the fear and vulnerability seen in patients coming from the security of an ICU environment to a ward. There is a need to increase staff awareness of potential difficulties for patients so that transfer can be seen as a continuity of the service (Whittaker and Ball, 2000).

Patient fear and anxiety - Patients were described as unsure, apprehensive and frightened. 'They're absolutely petrified when they come on to the ward and they're put in a bay or in a side-room and they haven't got that constant attention all the time.'

'Intensive care syndrome' can result in a patient having a reduced ability to cope with change such as a transfer to a ward environment. Contributing factors include sleep deprivation and altered sensory inputs (Dyer, 1995a; Gelling, 1999). At the same time as the one-to-one ratio of staff is lost, machinery and equipment may also be removed, causing another psychological blow for the patient. Participants in the study described how some patients would feel insecure without ICU monitoring equipment at their bedside.

Relocation stress - Patients who have been exposed to these potential risk factors who are then transferred to a ward environment are at risk of relocation stress (Box 1).

Relatives' anxiety - Relatives' anxiety was mentioned by three participants. The busy ward environment came as a shock to them after intensive care, as one nurse described: 'They might come in to a bay in the evening during visiting hours with three or four people round every bed and think, 'My God, what have we come to? How are they going to be able to look after him or her with all this going on?' You can see it on their faces sometimes.'

Introducing the family to the ward staff and environment before transfer was suggested as a way of helping reduce this anxiety: 'A lot of the time the patient is a bit overawed by it all really but the family are there wanting to know details ... there and then. If they'd met you before and relaxed with you, they'd probably disappear into the background and you'd be able to calm the situation down from the beginning.'

It is important that ICU staff create a positive picture of other nurses within the hospital so that patients can be assured that staff have the expertise to deal with emergencies (Saarmann, 1993). Seeing transfer as a progressive step towards recovery may enhance patients' and relatives' perceptions of the continuity of their care.

Limitations of the study
As a small pilot study of participants working in areas accepting transfer from one ICU, findings cannot be generalised to a wider setting. However, this was not the intention. The aim was to provide data to give an insight into the experiences of the participants. These could then be used to develop a questionnaire for distribution to a larger sample group at a future date.

There is a lack of perspective from junior nurses and nurses from areas taking infrequent patient transfers. The needs of this sample group may be very different. As the researcher is based in ICU there is a risk of bias due to personal experiences and role. Every attempt was made to provide a clear decision trail, detailing the steps taken to enhance validity and reliability of the findings. The use of a clear data analysis model, using independent inter-raters and validation of a category system with participants, aimed to enhance the 'trustworthiness' of the study (Holloway and Wheeler, 1996).

Intensive care staff were not included in this study, therefore it is not possible to compare views on any rationale behind the perceived lack of control over transfer and inadequate communication reflected by the participants.

Conclusion and implications for nursing
This was a pilot study representing the views of a small sample of qualified nurses working in acute ward areas and describes the difficulties they face when caring for patients who are transferred from an ICU.

The significance of obtaining the ward staffs' views is evident. The most frequently occurring difficulties they described were categorised under 'staff stress'. All participants described stress, anxiety or fear when expecting a patient from ICU. As a means of reducing stress, participants advocated improved discharge planning and closer liaison between ICU and ward areas.

The importance of staff mental welfare is now acknowledged at organisational level (DoH, 1997; DoH, 2000b). There is a new recognition of the significance of caring for these highly dependent patients and there is a need to identify ways of supporting staff to reduce stress. Specific concern for junior staff with limited practical experience has been raised.

Changes in the training of student nurses linking theory to practice are currently being piloted nationally (DoH, 1999). The benefits of ongoing professional development for staff have been recognised as essential to promoting public confidence in the NHS (NHS Executive, 1999).

All participants valued patient and staff follow-up on discharge from ICU. Participants described psychological symptoms in patients that could be attributed to relocation stress and their expectations of care in the ward caused significant difficulties. This has implications for practice in light of the need to obtain the views of patients (Audit Commission, 1999; DoH, 2000a; DoH, 2000c; DoH, 2000d).

Recommendations for further study
Improved planning for patients being discharged from ICU to ward areas and patient follow-up are areas requiring further study. Further research is also required to identify the perceptions of a much wider sample group of nurses caring for patients transferred from ICU.

Working towards a 'seamless service' with greater patient involvement and feedback means that it is crucial we establish a greater understanding of the difficulties identified by staff caring for these patients.

A 'demanding' patient can put staff in busy acute areas under great pressure. However, on closer observation, this reveals many potential complex physiological and psychological difficulties of which all staff, both in critical care and ward areas, need greater understanding if they are to continue to develop a high-quality service.

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