Improving patient care transitions from the intensive care unit to the ward by learning from everyday practice. A multicenter qualitative study

Objective: To explore and describe the everyday practices (Work-As-Done) that hinder and facilitate patient care transitions from the intensive care unit (ICU) to the ward. Research method/design: Multiple qualitative case studies in the ICU and various specialized wards of three Dutch hospitals. Adult patients planned to be transferred were purposively sampled on a variety of characteristics along with their relative (if present), and the ICU and ward nurses who were involved in the transition process. Data were collected by using multiple sources (i.e., observations, semi-structured interviews and a qualitative survey) and then systematically analyzed using the thematic analysis approach until saturation was reached. Findings: Twenty-six cases were studied. For each case, the actual transfer was observed. Sixteen patients, five relatives and 36 nurses were interviewed. Two patients completed the survey. Fifteen themes emerged from the data, showing that the quality of transitions is influenced by the extent to which nurses anticipate to patient- specific needs (e.g., providing timely and adequate information, orientation, mental support and aftercare) and to the needs of the counterpart to continue care (e.g., by preparing handovers) besides following standard procedures. Data also show that procedures sometimes interfere with what works best in practice (e.g., communication via a liaison service instead of direct communication between ICU and ward nurses). Conclusions: Subtle, non-technical nursing skills play an important role in comforting patients and in the coordination of care when patients are transferred from the ICU to the ward. I mplications for clinical practice: These Work-As-Done findings and their underlying narratives, that are often overlooked when focusing on quality improvement, can be used as material to reflect on own practice and raise awareness for its impact on patients. They may stimulate healthcare staff in crafting interventions for optimizing the transition process.