A Systematic Review of Relocation Stress Following In-House Transfer Out of Critical/Intensive Care Units

Review Objective The objective of this systematic review is to investigate the occurrence of relocation stress/transfer anxiety in patients and their families upon transfer of the patient from an intensive care unit to a non-intensive care unit and the effectiveness of strategies for decreasing this anxiety. Background Intensive care units comprise approximately 10% of U.S. acute care hospital beds 1 and 12% of Canadian acute care beds 2 With an aging population, and increasing acuity of illness of hospitalized patients, both the total number of intensive care unit patients and their proportional share of hospital admissions overall are expected to grow 3 For patients and their loved ones, admission into a critical care unit is fraught with fear and stress. Physiologic instability, fear of the unknown, lack of information, concerns of the future, and an unfamiliar, overwhelming environment all contribute to a rollercoaster of emotions that can be very uncomfortable. However, as patients and family members become familiar with the environment and staff, a sense of comfort and security develops 4 This comfort is challenged as the patient's condition improves and plans are made for transfer from the intensive care unit to the general floor. The transfer from ICU to the general floor has been documented to be associated with physiologic stress 5,6, physical symptoms 7 and psychological stress 8 that may mimic posttraumatic stress disorder 9 The anxiety associated with transfer is believed to affect recovery and create distress for relatives in the form of anxiety, uncertainty, and fear. 10 Transfer anxiety encompasses the feelings of stress and worry experienced by patients and relatives when leaving a critical care unit. Also termed relocation stress, the experience is viewed as a form of separation anxiety, arising when people move from a familiar, secure enviornment into one that is unknown 11. Lack of preparation as to the differences between the critical care unit and the new hosptial unit is a contributing factor in the experienced distress and patients and relatives knowledge about transfer varies greatly. 12 The subjective discomfort of transfer anxiety is thought to be greater with rapid, unplanned transfer that occurs with a demand for the critical care bed 13, 14. To facilitate continuity of care, critical care nurses must be cognizant of the challenges associated with transfer and proactively incorporate strategies to diminish this stress and anxiety, thereby facilitating a smooth transfer. Pre-transfer teaching strategies, reinforcement of physiologic progress, reduction in the amount of moniotring and supportive equipment used in the critical care unit, timing of transfer, pretransfer care conferences, and use of liaison nurses have been suggested as useful in minimizing anxiety and easing the transition. Objectives The overall aim is to conduct a mixed methods systematic review to determine the occurrence and meaningfulness of relocation stress and the effectiveness of strategies for decreasing transfer anxiety in patients and their families upon transfer from an intensive care unit to a non-intensive care unit. Specifically the systematic review will seek to determine: The evidence on the frequency of negative relocation stress. Factors associated with relocation stress experienced as a positive, neutral or negative event The meaning of the experience of relocation to patients and family members Strategies found to be effective in the prevention or resolution of transfer anxiety Strategies found feasible in the prevention or resolution of transfer anxiety Inclusion Criteria Participants: The review will consider studies involving adult intensive care patients, their family members and adult intensive care nurses. Types of Interventions/Phenomena of Interest The qualitative component of this review will consider studies that investigate the meaning of transfer from ICU to the general unit for patients and their families. The quantitative component of this review will examine interventions aimed at decreasing anxiety and facilitating the transition from ICU to the general floor/nursing ward. These interventions include: Teaching approaches for either the nurse or patient and their family Reduction in patient monitoring Timing of transfer Care conferences Liaison approaches Outcomes: The quantitative component of this review will consider studies that include the following outcome measures: anxiety levels, fear, uncertainty, knowledge, satisfaction and physical changes in blood pressure, heart rate and catecholamine response. Outcomes of the qualitative component of this review will include experiential accounts of transfer from intensive care unit to the general floor of the patient, family members and intensive care nurses. Types of Studies: The quantitative component of this review will consider randomised controlled trials, controlled trials, cohort studies, case-control studies, before and after studies and case series that examine the effectiveness of interventions such as education and monitoring approaches on outcomes of relocation stress such as anxiety, fear, uncertainty, knowledge, satisfaction, vital sign changes and catecholamine response as a result of the transition from the ICU to general floor. The qualitative component of the review aims to examine the meaning of the transfer experience from ICU to the general floor as well as the feasibility of decreasing the stress or easing the transition. This review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, ground theory, ethnography, and action research. In the absence of research studies, other text such as opinion papers and reports will be considered. Search Strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilised in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Initial keywords to be used are: Transfer, Patient transfers Transfer stress Transfer anxiety Relocation Relocation Stress Translocation syndrome Discharge Critical Care Intensive Care Cardiac Care Continuity of Care Keyword and Index Terms across Databases Medline 1950- 1. exp Stress, Psychological/ 2. exp Exertion/ 3. transfer stress.mp. 4. “ICU liaison nurse”.mp. 5. exp Intensive Care Units/ 6. exp Patient Transfer/ 7. exp Critical Care/ 8. Anxiety/ 9. “transfer anxiety”.mp. 10. relocation stress.mp. 11. exp Adaptation, Psychological/ 12. Intensive Care/ or Intensive Care Units/ or Critical Care/ or Critical Illness/ 13. Intensive Care/ or Intensive Care Units/ or Critical Care/ 14. ((icu or intensive care or critical care) adj6 cardiac).mp. [mp=title, original title, abstract, name of substance word, subject heading word] 15. (relocat* adj10 stress).mp. [mp=title, original title, abstract, name of substance word, subject heading word] 16. translocation syndrome.mp. 17. from 16 keep 2,5 18. (step down unit or observation unit).mp. [mp=title, original title, abstract, name of substance word, subject heading word] 19. relocation anxiety.mp. 20. 11 or 3 or 9 or 2 or 8 or 1 or 10 or 19 21. 13 or 14 22. 21 and 20 23. 22 and 6 24. from 23 keep 2-5,7-10,12-20,22-28 25. from 15 keep 2,5,18,30,40-41,43,58,64,71-72 26. 6 and 14 27. from 26 keep 2 Ovid Healthstar 1966 to August 2008 Transfer stress 1. exp Stress, Psychological/ 2. exp Exertion/ 3. transfer stress.mp. 4. “ICU liaison nurse”.mp. 5. exp Intensive Care Units/ 6. exp Patient Transfer/ 7. exp Critical Care/ 8. Anxiety/ 9. “transfer anxiety”.mp. 10. relocation stress.mp. 11. exp Adaptation, Psychological/ 12. Intensive Care/ or Intensive Care Units/ or Critical Care/ or Critical Illness/ 13. Intensive Care/ or Intensive Care Units/ or Critical Care/ 14. ((icu or intensive care or critical care) adj6 cardiac).mp. [mp=title, original title, abstract, name of substance word, subject heading word] 15. (relocat* adj10 stress).mp. [mp=title, original title, abstract, name of substance word, subject heading word] 16. translocation syndrome.mp. 17. (step down unit or observation unit).mp. [mp=title, original title, abstract, name of substance word, subject heading word] 18. relocation anxiety.mp. 19. 11 or 3 or 9 or 2 or 8 or 1 or 10 or 18 20. 13 or 14 21. 20 and 19 22. 21 and 6 23. 6 and 14 24. from 23 keep 2 25. from 22 keep 3 26. from 21 keep 40,54,73,111,180,231,238,240,263,271,315 27. from 17 keep 36,38,132 28. from 15 keep 5,13,24,28,30,38,40,44,50 29. from 28 keep 3 CINAHL1982- 1. exp Stress, Psychological/ 2. exp Exertion/ 3. transfer stress.mp. 4. “ICU liaison nurse”.mp. 5. exp Intensive Care Units/ 6. exp Patient Transfer/ 7. exp Critical Care/ 8. Anxiety/ 9. “transfer anxiety”.mp. 10. relocation stress.mp. 11. exp Adaptation, Psychological/ 12. Intensive Care/ or Intensive Care Units/ or Critical Care/ or Critical Illness/ 13. Intensive Care/ or Intensive Care Units/ or Critical Care/ 14. ((icu or intensive care or critical care) adj6 cardiac).mp. [mp=title, subject heading word, abstract, instrumentation] 15. (relocat* adj10 stress).mp. [mp=title, subject heading word, abstract, instrumentation] 16. translocation syndrome.mp. 17. (step down unit or observation unit).mp. [mp=title, subject heading word, abstract, instrumentation] 18. relocation anxiety.mp. 19. 11 or 3 or 9 or 2 or 8 or 1 or 10 or 18 20. 13 or 14 21. 20 and 19 22. 21 and 6 23. 6 and 14 24. from 23 keep 2 25. from 22 keep 3 26. from 21 keep 40,54,73,111,180,231,238,240,263,271,315 27. from 17 keep 36,38,132 28. from 15 keep 5,13,24,28,30,38,40,44,50 Unpublished Studies The following databases will be searched for unpublished studies: Dissertation Abstracts International ProQuest- Dissertations & Theses Communication with key organizations and key researchers in the area Grey Literature A Grey Literature search will be conducted through New York Academy of Medicine, RAND and SCIRUS. Assessment of Methodolgical Quality All retrieved papers will be assessed for methodological quality independently by two reviewers, using the appropriate JBI critical appraisal assessment tools (Appendices I - III). Any disagreements that arise between the reviewers will be resolved through discussion, or in consultation with a third reviewer. Data Collection Relevant JBI data extraction tools will be used to extract data from quantitative studies, qualitative studies and opinion pieces (Appendices IV - VI). This process will be undertaken by two reviewers working independently. The data extracted will include specific details about the phenomena of interest, interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data Synthesis Quantitative papers will, where possible be pooled in statistical meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI, Appendix V). All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form. Qualitative research findings will, where possible be pooled using the Qualitative Assessment and Review Instrument (JBI-QARI, Appendix IV). This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rates according to their quality, and categorising these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a metasynthesis in order to produce a single comprehensive set of synthesised findings (Level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form. Textual papers will, where possible be pooled using the Narrative, Opinion and Text Assessment and Review Instrument (JIB-NOTARI, Appendix VI). This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, through assembling the conclusions to generate a set of statements that represent that aggregation, through assembling and categorising these conclusions on the basis of similarity in meaning. These categories are then subjected to a metasynthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the conclusions will be presented in narrative form. Conflicts of Interest There are no conflicts of interest. The reviewers are employed in education and clinical service.

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