Development and pilot testing of a clinical nursing guideline for transition of psychosocial care from the intensive care unit to the ward in Malawi

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Aim and purpose: The study’s aim was to develop, and pilot test a clinical guideline for the transition of psychosocial care from ICU to the ward environment at QECH, to inform nursing practice. The purpose was to provide safe and efficient transitional care to patients recently transferred from ICU and their families. Research methods: The study employed mixed research methods using a pre- and post-test intervention, conducted in three phases: exploratory, development and verification and pilot testing phase. Data collection: In phase one, semi-structured researcher-administered individual interviews were conducted with patients recently transferred from ICU and their families, multidisciplinary teams, including medical clinicians and nurses, purposively sampled to solicit their expert opinions and/or experiences with transition of care in order to include their views in the clinical guideline to make it effective. In phase two, data obtained from phase one were analysed using content analysis and presented in narrative form. An integrative review of literature provided evidence-based practice in transitional care. A draft clinical guideline was developed based on the results of phase one and the integrative literature review. The draft clinical guideline was verified by the clinical staff and academic critical care experts, representatives of professional bodies and the Ministry of Health, patients recently transferred from ICU and families to seek and incorporate their opinions and/or experiences with transition of care from ICU to the wards. In phase three, the split ICU and ward-specific clinical guidelines were pilot tested, and outcomes assessed on patients recently transferred from ICU and their families using the same instruments pre- and post-intervention. The conducting of structured individual researcher-administered interviews, was to assess anxiety as a primary outcome, and satisfaction with care as a secondary outcome. In total, 65 paired patients and families were interviewed pre- and post-intervention. Descriptive and inferential statistics presented demographic data, anxiety levels and degree of satisfaction with care. A comparison conducted between the pre- and post-intervention groups determined the effect of the vii intervention on outcome variables. Additionally, post-intervention, one focus group discussion was conducted with the ICU and ward multidisciplinary teams to re-assess their views with regard to the developed clinical guidelines for transition of care from ICU, for their incorporation into the final clinical guidelines. Results: The qualitative study and the integrative literature review both revealed that patients recently transferred from ICU and their families as recipients of ICU psychosocial care and the multidisciplinary teams from ICU and the wards as providers of the care overall experienced anxiety and dissatisfaction with ICU psychosocial transitional care. The major challenge was communication. Nursing strategies for improving the ICU psychosocial transitional care practice were identified from the two studies which resulted into development of ICU and Ward-specific nursing clinical guidelines each comprising four components with specific recommendation statements for addressing them. These included (1) effective provision of psychological care to patients and families; (2) effective communication among ICU and ward nurses and with patients and families; (3) adequate discharge preparation of patients, families and the receiving wards; and (4) follow up of patients and families in the wards. The clinical guidelines were pilot tested pre- and post-intervention. The comparison of the results from the two periods, indicated that the intervention significantly reduced the level of anxiety and increased the degree of satisfaction with care both in the ICU and the wards. Descriptive and comparative statistical tests were utilized to analyze the data while employing the Mann-Whitney tests. Testing was done on the 5% level of significance (p = <0.05) A Mann-Whitney U test demonstrated that anxiety scores were significantly lower in the post-intervention test group (median=10.5, n=65) compared to the pre-intervention test group (median=30.5, n=65), U =.000, Z = -5.410, p =.000, and W = 210.00. The effect size r=0.67, which indicates medium effect; 0.2=small effect, 0.5=medium effect, and 0.8=larger effect. As a result, the hypothesis was supported. Additionally, a Mann-Whitney U test revealed that satisfaction of participants in ICU in the post-intervention test group (median =21.36, n = 65) was substantially higher than in the pre-intervention test group (median =7.64, n = 65), with U = 194.0, Z = 4.411, p =.000, and W = 299.0. The effect size is 0.55, indicating a medium effect; 0.2 suggests a little effect, viii 0.5 indicates a medium effect, and 0.8 shows a high effect. As a result, the hypothesis (H1) was accepted. Similarly in the wards, with U = 52.0, Z = -2.114, p = .03, and W = 157.0, a Mann-Whitney U test revealed that satisfaction was considerably higher in the postintervention test group (median =11.21, n = 65) than in the pre-intervention test group (median =17.79, n = 65). The effect size is 0.26, which indicates a small effect; 0.2 indicates a small effect; 0.5 indicates a medium effect; and 0.8 indicates a larger effect. As a result, H1 received approval. Furthermore, the transitional care practice by the nurses also improved, which contributed to the patients’ and families’ positive experiences with the care.
A thesis submitted in fulfilment of the requirement for the degree Doctor of Philosophy to the Faculty of Health Sciences, School of Therapeutic Sciences, University of the Witwatersrand, Johannesburg, 2021