Susan W. Salmond, RN, EdD UMDNJ School of Nursing New Jersey Center for Evidence Based Practice

Susan W. Salmond, RN, EdD UMDNJ School of Nursing New Jersey Center for Evidence Based Practice

A form of separation anxiety, arising when people are required to move from a familiar, secure environment into one that is unknown. (Roberts,1986) Suggests an inevitable consequence of the psychological adjustment involved in transfer The feelings of stress and worry experienced by patients and relatives upon transfer out of ICU (McKinney & Melby, 2002)

Transfer anxiety is assumed Associated with physiologic and psychological stress The anxiety associated with transfer is believed to affect recovery Most commonly referenced articles are non-empirical, literature reviews

CSR Mixed Methods

The evidence on the frequency of negative relocation stress? The meaning of the experience of relocation to patients and family members? Factors associated with perceptions of transfer as a positive, neutral or negative event? Strategies found effective/feasible in the prevention or resolution of transfer anxiety?

Participants: Phenomenon of Interest: Adult ICU patients, their families and care providers Meaning of transfer from ICU to floor Types of Interventions: Teaching approaches Timing of transfers Liaison approaches Independence strategies

Outcomes Anxiety Levels Fear Uncertainty Knowledge Satisfaction Physical Changes Experiential Accounts Types of Studies English Only Qualitative Quantitative

Search to locate existing CSRs Initial limited search for key words Transfer + Stress, Anxiety Relocation+ Stress, Anxiety Translocation Discharge

Database Comprehensive Search Grey Literature Reference Checking Hand Searching Intensive and Critical Care Nursing

Congruence with Inclusion Criteria 2 Persons

783 abstracts reviewed 657 excluded and not retrieved 126 articles retrieved 91 articles not meeting inclusion criteria 35 studies met inclusion criteria and critically appraised

35 studies met inclusion criteria and critically appraised 17 Quantitative Studies Appraised 1 Practice Guideline Appraised 17 Qualitative Studies Appraised

Used JBI Critical Appraisal Tools Qualitative semi-structured interviews, 15 phenomenological interviews, 3 focus groups, 1 Quantitative survey, 2 quasiexperimental, comparative 6 Practice Guideline

Author, Year # of Yes Items on Critical Appraisal Reason for Exclusion Bokinskie 15, 1992 3/10 Design issues preclude confidence in findings Cutler & Garner 16, 1995 0/10 Design not described. Statistics not provided.

Note: All U.S. studies were from earlier decades

Transfer anxiety, defined as separation anxiety, is not universal Empirical data found low levels of moderate to high anxiety Greater than 50% have positive responses Some neutral

o Spielberger s State/Trait Anxiety Inventory (STAI) state anxiety subscale o Hospital Anxiety & Depression Scale (HADS) o Graphical Anxiety Rating Scale (GARS)

Perceptions of Transfer: Positive, Negative, Neutral

53% (Green, 1996) 73% (Hackett, 1968) 50% for patients (Leith, 1999) >60% for families (Leith, 1999) 46% (Smith, 1976)

18% (Hackett, 1968) 19% (Hall-Smith, 1997) 20% (Leith, 1999) 16% (Smith, 1976)

o Positive Response More Common than Negative Response o No Real Guide to Practice o To Understand the Phenomenon More, Need Qualitative Data

o 17 Studies o Primary article Finding becomes Subject o Findings from multiple studies are collapsed into categories oinvolves some interpretation o Categories are collapsed into synthesis statements

Finding Illustration Feeling Renewed On the Road to Recovery I felt renewed as if 1,000 pounds had been lifted from my back It s a milestone. I have got this far and I am very glad for it

Finding Negative Emotional Response Not Prepared Illustration It was a complete shock an awful experience to be honest It was okay but I was anxious, nervous I felt the world had been kicked out from underneath me It was frightening

Finding Illustration Detached acceptance It didn t matter much to me. I figured that the ICU staff wouldn t transfer me if I wasn t ready It s alright, not a problem

Some described ambivalence oscillating between pleasure and fear and doubt For most, doubt or negativity did not occur until the person experienced the full impact of being in the ward Out of the protective bubble of ICU, anxiety, uncertainty and fear of being unobserved

Positive Perceptions Differing and shifting emotional responses Neutral Ambivalence Negative Perceptions

Conflicted Acceptance Varying levels of acceptance and meaning On the Road to Recovery Resigned Acceptance Desire for Normalcy

For most, there is a positive response amidst vacillating emotions and level of acceptance. A small subset of patients and family members are at risk for relocation stress Differing and shifting emotional responses Varying levels of acceptance and meaning 14 Findings 13 Findings

One Among Many Leaving the protective cocoon engenders vulnerability Reemergence of Vulnerability Confusion/Lack of Recall ICU as a Protective Cocoon

Physical Debilitation Physical debilitation within conflicting expectations of independence Unresponsive to Functional Dependence Opposing Expectations for Independence Emotional Response of Recovery

Feeling alone and vulnerable while trying to cope with physical and emotional challenges Leaving the protective cocoon engenders vulnerability Physical debilitation within conflicting expectations of independence 18 Findings 15 Findings

Care/Caring Impediments with communication breakdowns Care routines with less individualization Mechanistic Care No Knowledge of Whole Experience Ward Org & Environment

ICU Liaison Role Strategies to lessen uncertainty and anxiety Manage Uncertainty Facilitate Continuity Psychosocial Care

ICU Liaison Role Vulnerable systems of transfer No Control & Communication at Transfer Nursing needs and workload pressure Clinical Skills Knowledge Deficits

Care routines with less individualization 7 Findings Nursing Approaches and system consideration ease transfer stress Strategies to lessen uncertainty and anxiety 16 Findings Vulnerable systems of transfer 9 Findings

Are there definable factors associated with perceptions of transfer as a positive, neutral or negative event? Preparation for expectations Timing from preparation to transfer (Russell, 2000) Degree of the gap between dependence and independence across units

Transfer anxiety is not inevitable anxiety arising from leaving a protected environment Transfer anxiety occurs pretransfer in a small percent of patients and is aggravated by lack of preparation Anxiety is a more common finding secondary to the differential level of care and basic nursing care deficits experienced once on the unit

o Qualitative findings report relocation distress more similar to definition of stress and worry experienced upon transfer out (McKinney & Melby, 2002) o Knoop (2008) challenged whether relocation stress is a syndrome

Structured programs/approaches to educate and set expectations Brochures as guides for instruction Educational/transfer checklists Liaison nurse Family Conferences Reassurance re improvement and ability for less direct care, less 1:1 or monitoring Preparation on expectations of care in new unit

Hand-offs Must address functional abilities and limitations Should provide an overview of what patient and family have been through Designated individual to focus on transfers Clinical Nurse Leader Clinical Nurse Specialist Liaison Nurse Ward nurses need support and development Better understanding of physical, psychological and emotional stressors associated with transfer and in care of patient from ICU