Adequate preparation of critically ill patients throughout their transition experience within, and following discharge from the Intensive Care Unit is an important element of the nursing care process during critical illness. However, little is known about nurses’ perspectives of, and engagement in, caring for critically ill patients during their transition experiences.
This paper aims to review the literature about the concept of transition within the context of critically ill patients in the Intensive Care Unit, focusing on Intensive Care Unit nurses.
CINAHL, MEDLINE, OVID, Science Direct, SAGE eReference and SAGE Journal Online data bases were searched for relevant literature published since 1970.
The critically ill patients’ transitions in intensive care units are generally described as a period of transfer or change of situation, or the experience of inner change or role during and after the illness. The critically ill patients’ transition experience per se is not directly described, nor is nurses’ understanding of it.
Nurses’ understanding of critically ill patients’ transition may significantly impact the patients’ care in the Intensive Care Unit. Thus, research is needed that focuses more on evaluating nurses’ understanding of patients’ transition and its consequences.
Keywords: Nursing, Nurses, Intensive Care nurses, Patients, Critical illness, Transition, Patients’ transition
Transition is a concept that can be described as a process and an outcome. The concept offers a key to interpreting person-illness-environment interactions in terms of their actual and potential effects on health . Thus, careful conceptualisation of transition and its bio-psychosocial-cultural consequences may assist in providing therapeutic nursing to critically ill patients. Such patients generally require a ‘package of care’ to support their complex needs while they regain good health . Improved management of patients in the acute phase of a critical illness may increase their chances of survival but does not guarantee a return to full health . Hence, appropriate preparation of patients throughout their health and illness transitions is a vital aspect of recovering from critical illness.
AIM AND REVIEW METHOD
This paper aims to review the concept of transition within the context of critically ill patients, focusing on Intensive Care Unit nurses.
Various combinations of the terms transition, transition experience, transitional care, transfer, critically ill patients and ICU nurses’ perception were entered into CINAHL, MEDLINE, OVID, Science Direct, SAGE eReference and SAGE Journal Online data bases. The key search combination was ‘transition and ICU patients’ transition and critically ill patients and intensive care transition’. Search limitations included English only publications from 1970 to the present. The search resulted in 3270 articles about intensive care and critically ill patients’ transitions. Of these, only 49 related closely to the concept of transition. All are included in this review due to the limited number of publications on the topic.
RESULTS AND DISCUSSION
Defining the concept of transition
The term ‘transition’ is derived from the Latin verb ‘transire’, meaning to go across . The original meaning is reflected in today’s meaning: a ‘passage from one state, stage, subject, or a change of place to another or a movement, development, or evolution from one form, stage, or style to another’ (Macquarie English Dictionary, 2006, 1303).
In nursing terms, transition can be defined as follows:
Transition can be said to occur if an event or non-event results in a change in assumptions about oneself and the world and thus requires a corresponding change in one’s behaviour and relationship
A passage from one life phase, condition, or status to anotherâ€¦ both the process and the outcome of complex person-environment interaction. It may involve more than one person and is embedded in the context and the situation. Defining characteristics of transition include process, disconnectedness, perception and patterns of response .
Movement or passage between two points and in the transitional process that involves transformation or alteration. The term is also used in relation to a process of inner-reorientation as a person learns to adapt and incorporate new circumstances into life (Kralik et al., 2006, 324).
Anthropologist Van Gennep described the process involved in acquiring a new status as having three phases: separation; transition; and incorporation. Van Gennep’s central idea is that each phase signifies a change from one state to another; transition is a kind of no-man’s land in which the individual is between social categories and emerges from the transition with a new persona.
Similarly, Schlossberg (1981) developed ‘Transition Theory’ to create a framework to enable practitioners to understand why people react and adapt so differently to transition; and why the same person can react and adapt differently at different points in life. Schlossberg’s revised theory consists of three components: transition; the transition process; and coping with transition. Thus, to adjust to, or cope with a changing situation, a person who experiences the process of moving into a new place will need to learn the new system’s rules, regulations, norms and expectations. When a person is experiencing the process of moving through, they are in survival mode. When they are going through the process of moving out, they may experience feelings of grief, even if they perceive the transition to be positive. Individuals experiencing such feelings may view self-initiative with ambivalence . Hence the importance of nurses understanding the critically ill patients’ transition experiences and supporting those patients.
Characteristics of transition
Some transitions may be associated with an identifiable marker event such as diagnosis of illness, while others may not (Meleis et al., 2000). Transition will affect certain aspects of an individual’s life more than others, and the extent and intensity will vary over time. Illness, recovery and death are likely precursors to the process. Each critical point requires the nurses’ attention, knowledge and experience in different ways.
Awareness is related to knowledge, perception and recognition of a transition experience; it is often reflected in the degree of congruence between what is known about processes and responses, and what constitutes an expected set of responses and the perceptions of individuals undergoing similar transitions (Meleis et al., 2000, 7). These characteristics suggest that differences in perception and awareness of transition events influence responses to such events.
Disconnectedness, perhaps the most pervasive characteristic of transition (Chick & Meleis, , is associated with disruption to the person’s feelings of security: loss of reference points; incongruity between expectations based on the past and perceptions dictated by the present; and discrepancy between needs and access to the means to meet them. The degree to which each person demonstrates involvement in the transition process defines their level of engagement with it . For example, seeking information, being actively involved in preparation for transition or proactively modifying activity to cope with transition phenomena demonstrate a person’s level of engagement. The level of awareness influences the level of engagement in that engagement may not happen without awareness.
Transition is also characterised by movement over time . Bridges characterises transition as a time span with an identifiable end point, extending from the first sign of anticipation, perception or demonstration of change through a period of instability, confusion and distress to an eventual ending with a new beginning or period of stability.
All transition involves change; not all change is related to transition . Change occurs in an abrupt manner, whereas transition is a long-term process resulting in new meaning and a sense of mastery. Confronting difference is another property of transition and, when an individual feels different, their unmet or divergent expectations are perceived as different or seeing the world in different ways. Thus, it is useful for nurses in the Intensive Care Unit to consider a patients’ level of comfort and mastery in dealing with change and difference.
Types of transition experienced by critically ill patients
Three types of transition have been identified in relation to critically ill patients: health-illness transition; developmental transition; and situational transition.
The concept of transition in health-illness has been explored through individual and family responses in illness contexts . Meleis et al. state that changes in health and illness create a process of transition, and patients in transition tend to be more vulnerable to risks. Critically ill patients face several transitions throughout their care pathways as they move across boundaries of care from admission to discharge home . These patients and their families need preparation to anticipate unexpected urgent transitions.
Developmental transitions relate to individual or family responses to life cycle changes. Despite being ill, patients may experience developmental transitions during or after their stay in the Intensive Care Unit. Life transition (illness) for children with cardiac conditions or cancer , for example, is accompanied by their developmental transition throughout their illness. Changes in health and behaviour such as agitation, pain and discomfort resulting from critical illness and staying in the Intensive Care Unit may affect a child’s ability to develop physically and mentally at an optimal level .
Situational transition may involve various role transitions such as returning to school , or changes in a nurse’s role as a result of returning to practice or patients’ different needs. Alternatively, transition may involve changes in a family situation or relocation from one care setting to another. Critically ill patients experience situational transition when they have to change their role from that of a normal person to a sick person (patient) during hospitalisation and medical treatment . Patients also experience situational transition when they are relocated to the critical care and general wards as their condition deteriorates or improves. Situational transition is known to impact on Intensive Care Unit patients’ experiences, making it important for nurses to understand these in order to provide psychological support and more holistic care .
Critically ill patients’ transition in the Intensive Care Unit
Critically ill patients are at highest risk of death and permanent disability, and require admission to the Intensive Care Unit (Watts & Gardner 2005). Their care pathway may be very long or short, cyclical or linear depending on the severity of their illness and their response to treatment. Critically ill patients with severe and irreversible underlying pathologies need psychological support to meet a peaceful death or survive a life-threatening event. These patients experience health-illness and situational transition throughout their admission and critical illness.
Critically ill patients in the Intensive Care Unit often experience multiple transitions as they move through different levels of care , and from treatment to survivorship. The patients’ underlying pathology and physiological changes may be treated and managed until their condition stabilises or they recover, when they will be transferred to another location such as the step-down unit for further management until they are ready to be discharged home. At this point, the patients and their family members may experience another transition.
Based on Chaboyer et al.’s (2005a) identification of critically ill patients’ multiple transitions, it is evident that these patients’ recovery may not be straight forward. Although approximately two in three patients will survive, that does not necessarily mean a return to full health . It is known that some patients may not recover their former functional capacity or pre-crisis health status They require complex care and ongoing support . Patients may experience mild to moderate physiological or psychological symptoms that may affect their quality of life and health status long term . Their families need to accept and anticipate the impact of critical illness or death. Preparing families for this is a very difficult task for nurses.
Residual and further progression of the condition that led to admission or new morbidity secondary to the Intensive Care Unit admission may complicate and prolong recovery from critical illness, with patients who have been critically ill continuing to face a multitude of physical, psychological, social and financial difficulties in the long term . Early transfer to step-down wards and early discharge from hospital can exacerbate these issues. When the patient returns home, for example, they and their family have to face another health event that necessitates further transition; one or more family members will be required to provide care giving assistance. Nurses, therefore, play an important role in preparing the patients and families to cope with these problems, which are part of the transition experience.
The most commonly identified problems among patients discharged from Intensive Care Units or hospitals are anxiety, relocation stress , depression and post-traumatic stress disorder. According to Coyle (2001), there is a chance that discharge may induce stress or distress in some patients, especially when routines, environment and/or invasive monitoring procedures alter or cease without the patient’s prior knowledge; that is, when there is lack of preparation or inadequate explanation from health professionals. Detrimental effects may extend far beyond transfer from the Intensive Care Unit, with short- and long-term outcomes likely to take a significant toll on patients and families, , as well as on the health professionals who care for them in different, multidisciplinary contexts .
The literature discussed thus far has identified that critically ill patients make several transitions across care settings during their recovery or towards palliative care. Each transition poses unique challenges for patients, families and the health care professionals involved in patients’ care . Each time the patients reach a transition in their illness they encounter changes in care management and care settings when obtaining care that is appropriate for their needs. However, each care setting has a boundary of care that is discrete and isolated from another, and each boundary increases the potential for fragmented care (Leith, 1998). Therefore, proper planning and care intervention in response to patients’ transition is essential.
Nurse-client encounters often occur during transitional periods of instability precipitated by developmental, situational or health-illness changes (Schumacher & Meleis, 1994). It has been proven that early transfer of patients from the Intensive Care Unit ‘sooner and sicker’ complicates the nurses’ intervention in meeting the needs of patients in the general ward (medical or surgical) where there is little therapy and less equipment . Thus, despite initial recovery from critical illness, many patients may deteriorate after transfer from the Intensive Care Unit.
Intensive Care Unit nurses need to provide holistic care, which requires higher than usual levels of nurse/family interaction, to each patient and their family members throughout multiple transitions (McKiernan & McCarthy, . Families need accurate and consistent information about the real situation so that they can make sense of what is happening to their loved ones, and prepare for current and future transitions . Therefore, a philosophy of family centred care is necessary, involving formal assessment of families soon after admission and an appropriate care plan drawn up at this time.
Planning to fulfil the patient’s need for adequate care of their complex needs as a result of transition in heath-illness is an aspect of nursing practice that can be difficult to accomplish. Critically ill patients need more comprehensive transition planning that entails anticipating transition and overcoming its effects. This planning must also account for the effects of crossing boundaries of care because multidisciplinary teams manage patients across multiple environments. Studies show increased rates of medication errors, incomplete or inaccurate information transfer, and lack of patient follow-up care with patients transitioning from hospital to home compared to those patients prepared and coached for the transition from the Intensive Care Unit to the general ward . However, Transitional Care for critically ill patients or Intensive Care Unit survivors tends to be planned at the final stage of the patient’s illness or near recovery, just before the patient is discharged home. Consequently, discharge planning for patients who travel across care settings may not be done properly, resulting in errors or discontinuity of care.
Nurses in the Intensive Care Unit have identified that discharge planning is not one of their norms and responsibilities . This may be due to a lack of understanding of the concept of transition, and the terms ‘discharge’ and ‘transfer’ as the patients are moved from the Intensive Care Unit. If nurses understand ‘transition’ as being similar to ‘discharge’, they may believe that Transitional Care, which includes planning, should only be done in the ward. Lack of understanding of the proper meanings and components of patients’ transition may cause misunderstandings about what should be done in response to patients’ experiences during the transition period.
Many patients are discharged with special invasive devices or therapeutic equipment, or procedures to be performed to maintain their care. Consequently, critical care nurses not only manage haemodynamic instability but also prepare patients and families for early discharge from the hospital . Additionally, transfer to the general ward after critical illness or with new illness problems after major surgery can be distressing and depressing after the Intensive Care Unit experience (Agard & Harder, 2007). Thus, preparation of patients for these health events and transitions is required. It begins with admission to the Intensive Care Unit and continues until the patients are transferred to the general wards.
The nature of general wards can complicate the situation for critically ill patients with known complex needs. Studies have identified that nursing and medical ward staff lack the knowledge to manage acutely ill patients and do not appreciate clinical urgency, detect deterioration early or communicate effectively . Patients no longer have one-to-one nursing care. They have to compete for staff time for basic needs and attention due to lower staff-patient ratios in the non-intensive care environment . Thus, nurses need to ensure that patients who leave the Intensive Care Unit and the hospital receive appropriate preparation for the transition and continuity of care. It is crucial for nurses to understand the concept of transition and its consequences so they understand how to respond to the patients’ needs. However, the literature reveals that nurses think of transition as various events that cause changes. Most nurses focus on transition of patients’ condition, role and care as they are moved to other locations . Most studies researched care for elderly patients with chronic illness such as cancer or mental illness, and who required situational transition (from one care setting to another). This focus seems at odds with the broader scope of transition, in which the focal point is the passage of one life phase, condition or status to another, involving the processes and outcomes of complex person-environment interaction. Health care professionals will be better equipped to support clients through the adaptation process if they understand the overall transition process .
Watts and Gardner showed that nurses do not understand the concept of transition. They explored nurses’ knowledge and practice related to discharge and discharge planning and found that discharge planning was done mainly after the patients had been transferred to the general ward. Other authors have also shown that nurses in the Intensive Care Unit did not see the need to carry out discharge planning early while the patients were still in the unit. If nurses understand the concept of transition experienced by the critically ill patients as a continuous process and also as an outcome, transitional planning might be done effectively and smoothly.
In contrast, another study on Intensive Care Unit nurses’ awareness of patients’ transition experience (Ludin, 2011) found that nurses identified health-illness and severity, consequences of transition, faith, fate and hopefulness, care, concern, emotional effects and moral distress as important elements of transition for the critically ill patient.
The nurses also expressed their understanding of what patients and their family members might be experiencing, to the point of either imagining or having experienced a role transition from being a nurse to being a mother, a daughter or family member to the patients. These nurses’ role as a nurse in that unit may have changed during the study, and this change may have influenced how they cared for the patients undergoing transition. Thus, nurses’ understanding of critically ill patients’ transition and their experience while caring for those patients would influence their nursing care.
The literature about transition implies that nurses need an improved understanding of critically ill patients’ transition experiences in the Intensive Care Unit to assist them in their therapeutic interventions for these patients. This is important because patients’ transitions impact on the patient, family and health professionals involved in the patients’ care. The lack of literature specific to nurses’ understanding of patients’ transition during their Intensive Care Unit stay is concerning. It is recommended that future research focuses on more evaluation of nurses’ understanding of the critically ill patients’ transition and its consequences.
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