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PATIENTS’ TRANSITION

What is it like in the Intensive Care Unit?

Discover the hidden realities from nurses’ perspective.

SALIZAR MOHAMED LUDINInternatioal Islamic University Malaysia

Co-authors: Professor Paul Arbon & Dr. Steve Parker)

OVERVIEW • Conceptualisation of

transition• Problem statement,

Research aims and questions• Methodology• Research setting, design &

methods• Ethical consideration• Data analysis• Rigor and trustworthiness• Findings• Interpretation & discussion• Recommendation• Summary

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Conceptualization of transition

• The term ‘transition’ is derived from the Latin verb ‘transire’, meaning to go across (Chick & Meleis 1986).

• The ‘Macquarie Concise Dictionary (2006, p. 1303) defines the noun transition as ‘passage from one state, stage, subject, or a change place to another or a movement, development, or evolution from one form, stage, or style to another’.

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Conceptualization of transition

Common definition of transition in nursing

• Transition occur if an event or non-event results in a change in about oneself and the world, thus requires a corresponding change in one’s behaviour and relationship (Schlossberg 1981)

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The individual in Transition Theory (Schlossberg 1984)

Helping adults in transition: A content process model (Schlossberg, Lynch & Chickering

1989)

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• A passage from life phase, condition, or status to another…refers to both process and outcome of complex person-environment interaction (Chick & Meleis 1986).

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• A process that involves three phases: ending, neutral, and a new beginning (Bridges 2003)

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Characteristics of transition

• Critical events• Awareness • Disconnectedness• Time span• Engagement• Change and difference

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Types of transition

• Health –illness• Developmental• Situational• Organizational

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Transition and Nursing

• The concept of transition is central to the nursing discipline because it focuses on the individual and their coping with the experience of clinical care (Meleis et al. 2000; Meleis & Trangenstein 1994).

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Nurse-client encounters that often occur during transitional periods and the period of instability which may produce profound alterations in the lives of individuals and their significant others, have important implications for well-being and health (Schumacher & Meleis 1994).

• Consequently, a transition theory framework can facilitate an understanding of individuals in transition and their access to the help they need to cope with the ordinary and extraordinary process of living.

• Such a framework may also be helpful in planning and providing more appropriate nursing interventions for patients experiencing transition.

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Critically ill patients context• Careful conceptualisation of transition and its

consequences in all the bio-psychosocial-cultural variations will assist nurses in providing therapeutic nursing to critically ill patients.

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• Critically ill patients recovering from critical illness often suffer lasting physical and psychological effects and generally require a ‘package of care’ to support their complex needs when getting back to good health or a near normal condition (Foust 2007).

• Adequate preparation of the critically ill patients and families is an important element of the recovering process.

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Transition and critical care nurses• Transitions fall into nursing domain when it pertains to health-illness

behaviours or when responses to the transition are manifested in health-illness behaviours (Chick and Meleis 1986, pg. 238).

• Nurses’ contribution in patients’ cont’ care during patients’ transition is important as the critically ill patients in the ICU experience multiple transition as they moves across different level of care Chaboyer (2005).

• Being transferred to a ‘general’ ward after severe critical illness or with consequential problems can be distressing and challenging.

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• This study naturally focus on discharge and change of the patients’ situation during critical illness, however it has been recognised that there is increased importance in awareness of critically ill patients and families transition experiences including the journey while in C/ICU and following discharge from the unit.

• As the critical and intensive care nurses are the primary caregivers in critical care contexts, their understanding of the critically ill patients’ transition is important to facilitate better nursing care and prepare the patients and families. 17

Critical care context

Critical illness

Health & illness transition experiences/journey

Multifaceted treatment/ care

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Problem statement

• Transition of life after health & illness- chronic illness

• Transition (movement) to other care setting- C/ICU patients

• Discharge and discharge planning in C/ICU

• Patients’ transition experience & nurses engagement in care

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Research aim

Understanding the critically ill patients and their families’ transition experience.

This is a vital aspect and it is argued that nurses should know how to assist patients and families during the transitions associated with hospitalisation and recovery from critical illness.

Salizar M Ludin

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Research question

What is the awareness of the critically ill patients’ transitional experience among the Malaysian C/ICU nurses?

MethodologyInterpretive Description

approach

Is a qualitative research approach that requires an integrity of purpose deriving from actual practice goal and an understanding of what we know and don’t know from all available sources (Thorne 2007, p. 35)

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The framework - needs within nursing science and focuses on developing knowledge that will inform clinical practice (Hunt 2009)

-experiential questions that are relevant to nursing in clinical area

Goes beyond description - in-depth conceptual description stays closer to the data obtained (Sullivan-Bolyai, Bova & Harper 2005).

The analytic procedures - synthesizing, theorizing and re-contextualizing rather than just simply sorting and coding (Thorne, Kirkham & O'Flynn-Magee 2004).

SETTING

HTAR

UMMC HKL

HSEL

Klang Valley (Selangor & K. Lumpur)

Four (4) public tertiary Hospitals in Malaysia

DESIGN & METHODS

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SAMPLING & TOOLS

Interview Focus group and in-depth-individual • Sampling-Purposive (5 FG and 10

individual interviews)

• Interview schedule– Semi-structured questions

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ETHICAL CONSIDERATION

• Flinders University Research Ethic Committee

• Economic planning unit, Prime Minister Dept. Malaysia

• National Medical Research Ethic Committee of Malaysia (government hosp)

• Hospital directors(teaching hosp)27

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DATA ANALYSIS

Analysis underpinned by the idea of Grounded theory technique (Strauss & Corbin 1998)

Interview (Group and individual)– Analysis tool- Nvivo8 software – Analysis method-GT method of analysis

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RIGOR AND TRUSTWORTHINESS

• Use of framework in data collection and analysis

• Participants’ confirmation of transcript

• Expert opinion-questionnaires

• Reliability test-questionnaire

• Pilot-testing-questionnaire & question guide

• Comparative analysis -GT analysis-back and forward analysis

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FINDINGS

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Theory of transition (Schlossberg 1981) - Experiencing transition (middle range theory)(Meleis et al 2000)

Continuous transition process

Patients / families experience

Nurses response 31

Comparison to previous model of transition

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INTERPRETATION & DISCUSSION

Conceptual model: Patients’ transition - What is it like in ICU from nurses

perspectives

Continuous Transition

Process

Transition experience

FAMILY

NURSE

C/ICU

Knowledge

Skills & care

Coping

Hope & faith Location change

Health-illness

PATIENTS

Family centred care

Education

Therapeutic use of self

PR

E-A

DM

ISS

ION

TR

AN

SF

ER

/ D

ISC

HA

RG

E

ADMISSION

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RECOMMENDATION

Nursing education• Broader definition of transition

Clinical practice• Broader definition of transition• Develop clear policies• Practical knowledge

Future research• Detail exploration of the concept• Observe the patients’ transition

experience• Test the conceptual model

Salizar M Ludin

CONCLUSION

Patients’ transition is about continuous

experiences through out their illness

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Co-authorsProfessor Paul Arbon

Dean- School of Nursing and MidwiferyFaculty of Health SciencesFlinders University, South Australia

• Email:       paul.arbon@flinders.edu.au

President -World Association for Disaster and Emergency Medicine (WADEM)

Director- Torrens Resilience Institute

Dr Steve Parker

Associate Dean (Teaching & Learning)- School of Nursing and MidwiferyFaculty of Health SciencesFlinders University, South Australia

• Email: steve.parker@flinders.edu.au36

REFERENCE

• Chaboyer, W, James, H & Kendall, M 2005, 'Transitional care after the intensive care unit', Critical care Nurse, vol. 25, no. 3 June, pp. 16-28.

• Boutilier, S 2007, 'Leaving critical care. Facilitating a smooth transition.', Dimention of Critical Care Nursing, vol. 26, no. 4 July- August.

• Foust, JB 2007, 'Discharge planning as part of daily nursing practice', Applied Nursing Research, vol. 20, no. 2, pp. 72-7.

• Meleis, AI, Sawyer, L, Im, E-O, Hilfinger, M, DeAnne, K & Schumacher, K 2000, 'Experiencing transitions: An emerging Middle-Range Theory', Journal of Advanced Nursing, vol. 23, no. 1, pp. 12-28

• Schlossberg, NK 1981, 'A model for analysing human adaptation to transition', The Counseling Psychologist, vol. 9, no. 2.

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• Bridges, W 2003, Managing transitions: Making the most of changes, Nicholas Brealey Publishing, London.

• Kralik, D, Visentin, K & van Loon, A 2006, 'Transition: A literature review.', Intergrative Literature Reviews and Meta Analyses.

• Hunt, MR 2009, 'Strenght and challenges in the use of Interpretive Description: Reflection arising from a study of the moral experience of health professionals in humanitatrian work.', Qualitative Health Research, vol. 19, p. 1284.

• Thorne, S, Kirkham, SR & MacDonald-Emes, J 1997, 'Focus on Qualitative Methods. Interpretive description: A Noncategorical qualitative alternative for developing nursing knowledge.', Research in Nursing and Health, vol. 20, pp. 169- 77.

• Thorne,S, 2007, Interpretive description. Walnut Creek, Carlifornia, Leftt Coast Press, Inc.

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