Abstract
Review question/objective: The objective of this review is to identify, appraise and synthesize the best available evidence exploring significant others' experiences of the discharge/transfer of patients after hospitalization.
More specifically, the review questions are:
What is the significant other(s) experience of hospital/discharge transfer of patients; in particular, experiences relating to transitions concerning organizational, psychosocial and existential issues?
How do significant others experience their preparedness for bringing the patient(s) home?
How do significant others experience the planning of discharge?
Background: Human beings, whether a significant other (SO) or patient are placed within a world they aim to understand: "Heidegger believed there were many ways for the human being to be-in-the-world but the most significant way was in being aware of one's own Being. That is, capable of inquiring into one's own Being, capable of wondering about one's own existence".1(p.68)Inquiring into one's own being as a SO or as a patient brings forward some of the existential questions and might also give some answers. This type of inquiry about one's own being in Heideggerian terms was named Dasein. For man to exist as Dasein is also to exist "authentically"1(p.68), because this gives access to awareness of one's own being in a life-world setting while simultaneously creating the risk of accessing suffering.2
Significant others are individual beings representing close family members (e.g. mother, father, sister, brother, husband, wife), other family relations (e.g. cousin, aunt, uncle, grandparents) or neighbors, friends, colleagues or members of the same household6, who act as relatives or surrogates.3 Significant others play an important role when patients are transferred or discharged after hospitalization. This event can be experienced as a complicated time for both the SO as well as the patient.4-5 In emergency situations, the separation and the isolated transfer of the mother during childbirth was experienced as inhibiting a mutual support between the mother and father-to-be.6 Significant others can act as caregivers as well, e.g. after discharge from ICU.5 These caregivers are often middle aged women who carry responsibilities for parents or a partner and children at the same time. However, males and children are also known as caregivers in families5, which may lead to additional 'home life' pressure which the SOs may experience.
Patients have expressed a need for the support of relatives, spouses and significant others in general during transfers.7 Patient transfer experiences have been described as unpredictable, scary and stressful when, for instance, the transfer is long-distance, and the environment seems unsafe or raises feelings of loneliness, longing for a spouse.7-8 Though transfer has been experienced as recovery and relief; transfer has also been experienced as a slide into insignificance which was very hard to recover from.
It is well documented how patients experience transitions during transfer.8 A meta-synthesis showed patients' experiences of transitions as critical events where the patients' needs involved feeling safe, and having a predictable and individually planned transfer.8 However, little is known about SO experiences of staff behavior and collaboration with patients regarding transfer (organizational). Or additionally, how planning and/or evaluation of transfer dealt with factors influencing patients' understanding of transfer (psychosocial) and how this was significant for each persons' (existential) transitions due to transfer.
Besides a few exceptions (e.g. Austria, Czech Republic, Japan, Netherlands), there is a tendency in the western hospital health care towards a reduction of the hospital bed density.9-10 Early discharge might burden the significant others beyond their ability to provide support and care. Therefore, it is still a question of how much further the length of stay at hospitals can be reduced.11
The SOs experience transfer as transitions characterized by healthy or unhealthy processes where meaning and awareness are being redefined or refused.12 Transition in this study is defined as follows: "a transition denotes a change in health status, in role relations, in expectations, or in abilities. It denotes changes in needs of all human systems. Transition requires the person to incorporate new knowledge, to alter behavior, and therefore to change the definition of self in social context, of a healthy or ill self, or of internal and external needs, that affects the health status".13(p.122)
In this review, we focus on organizational corporate culture from the perspective of SOs concerning their experiences from the following patient environments: hospital, nursing homes, primary health care teams and outgoing specialized care units. Organizational perspectives, understood within the context of "corporate culture" described by Curtin, seems to be able to influence the way SOs experience the hospital setting: "The corporate culture embodies the organizational values that implicitly and explicitly specify norms, shape attitudes, and guide the behaviors of the members of the organization".14(p.219) In addition to the organizational perspectives, SOs might experience psychological and social factors in the patient's and family's process of coping with the transfer in hospitals and discharge. Furthermore, it addresses psychological and social factors in the patient's and family's process of coping with an illness.15
In a previously published systematic review protocol Madsen 201416, we suggested exploring palliative patients' and their significant others' experiences of transitions during the course of incurable cancer; transitions were defined as experiences concerning organizational, psychosocial, and existential issues.16 Thus, the perspective of patients' experiences during transfer is being explored. Likewise, the perspective of nurses' professional experiences of patients' and SOs' transfer is similarly being investigated exploring nurses' experiences of caring for patients and their significant others during transitions that occur in the course of incurable cancer.17 This particular review is part of a later umbrella review concerning patients', significant others' and professionals' (RN) experiences of transfer. Therefore, it seems appropriate to identify evidence concerning SOs' experiences of patient transfer in general and from hospital to home in particular.
To the best of our knowledge no systematic reviews exploring SOs' experiences of hospital patients' transfer exist; therefore, we consider it important to provide evidence within this area to facilitate knowledge transfer into clinical practice aiming for evidence utilization.18
By conducting this review, we wish to contribute to the knowledge base on the SOs' experiences on patient transfer. The findings of this review might assist health care professionals in their clinical work to identify the transitional needs of the SOs when patients are transferred.
A preliminary search of the Joanna Briggs Library of systematic reviews, CINAHL, PubMed and PROSPERO databases revealed that there are no available systematic reviews or protocols on this topic.
Definitions:
For the purpose of this review the following definitions will be used16:
Patients: One who receives medical attention, care, or treatment in hospitals, nursing homes, from primary health care teams and outgoing specialized care units19
Significant other (SO): A person, such as a family member or close friend, who is important or influential in one's life.17
Experiences: Understood from a phenomenological-hermeneutic perspective: "focus is on the life world, open to the experiences of the subjects, a primacy of precise descriptions, attempts to bracket foreknowledge, and a search for invariant essential meanings in the descriptions".20(p.38-39)
Transfer: is understood as the movement from hospital to home.
Article Content
Inclusion criteria
Types of participants
The participants of this review will be the 'significant other(s); persons who are important or influential to the patient's life.
Phenomena of interest
This review will consider studies that investigate significant others' experiences of hospitalized patients' transitions during transfer from hospital to home.
Context
This review will consider studies that investigate the organizational culture during hospitalization and the psychosocial and existential issues.
Types of studies
This review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.
Search strategy
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of PubMed, Embase, PsycINFO, 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 the 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 and a citation search will also be done on particularly relevant studies. Studies published in English, Danish, German, Swedish, and Norwegian will be considered for inclusion in this review.
The databases to be searched include:
PubMed, CINAHL, PsycINFO, Embase
The search for unpublished studies will include:
Google Scholar, Mednar, and ProQuest
The search strategy was pilot tested April 10th/2014 with PubMed database resulting in 435 hits:
Search ((((((((Patient OR patients OR "young adult*" OR adult* OR "middle age*" OR age OR aged OR "80 and over" OR old* OR elderly OR "frail elderly")) AND (Hospital OR hospitals OR "hospital ward*" OR "hospital unit*" OR department*)) AND (Transition* OR transfer* OR discharge* OR "hand off" OR handoff* OR "hand-off*" OR handover* OR "discharge to home*" OR "going home*" OR "early discharge*" OR "patient discharge*" OR "discharge planning*" OR "discharge instruction*" OR "planning discharge*" OR "hospital discharge*"))) AND (((relative* OR family OR families OR parent OR parents OR mother OR mothers OR father OR fathers OR "next of kin*" OR "next-of-kin" OR son OR sons OR daughter* OR neighbour* OR "significant other*" OR colleague*)) AND (experience* OR comprehension* OR attitude* OR emotion* OR view* OR opinion* OR perception* OR belie* OR feeling* OR know* OR understanding* OR adaptation*))) AND (("1999/01/01"[PDat] : "2014/12/31"[PDat] ) AND (Danish[lang] OR English[lang] OR German[lang] OR Norwegian[lang] OR Swedish[lang] ) ))) AND ((organizational* OR organisational* OR psychosocial* OR psycho-social* OR "psycho social*" OR existencial* OR existential*) AND (("1999/01/01"[PDat] : "2014/12/31"[PDat] ) AND (Danish[lang] OR English[lang] OR German[lang] OR Norwegian[lang] OR Swedish[lang] ) ))
Assessment of methodological quality
Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Data collection
Data will be extracted independently by two authors from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives.
Data synthesis
Qualitative research findings will, where possible, be pooled using JBI-QARI. 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) rated according to their quality, and categorizing these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized 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.
Conflicts of interest
None
Acknowledgements
We wish to thank Research Secretary Line Jensen (MA) Department of Research, Horsens Hospital, Denmark for proofreading and Research Assistant Kirsten Jensen, Health, Aarhus University Library for assisting in producing the literature search plan.
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