Navigating the shift: a meta-synthesis of patient experiences and challenges in the intensive care unit-to-ward transition

INTRODUCTION

Transitioning from the intensive care unit to the general ward is a vulnerable phase for patients and caregivers. This transition indicates a step forward in a patient's recovery but it always comes with several challenges that impact patients and their families. In intensive care unit (ICU) facilities continuous monitoring and constant care by nurses are available which gives patients a feeling of emotional support and availability of healthcare support.¹ However, in the general ward, staff to staff-to-staff-to-patient ratio is lower than in the critical care unit which leaves patients feeling unprepared and unsupported, this increases their vulnerability during the transition. Research has shown that the transition phase is always accompanied by significant emotional stress for patients and families due to the unavailability of continuity of care during the transition.²

ICU-to-ward transition remains an underexplored area in healthcare research. Existing literature shows that there are gaps in the post-transition care support system in a current hospital setup.³ Another important gap identified by studies is the lack of communication and lack of formal education and training for the patients and caregivers during transition time.⁴ These issues highlight the critical need for targeted interventions that address these gaps and support patients in navigating the transition more effectively.

Understanding patient challenges in post-hospital transition and their experiences during this critical phase is important to improve health outcomes. Qualitative studies have highlighted the unmet needs of caregivers and the live experiences of the patients during the ICU-to-ward transition period.^1,2 These studies offer important insights into the emotional, financial, and informational challenges that patients face. However, the majority of research studies are fragmented indicating the need for a thorough synthesis that can provide an in-depth insight into patient's challenges and implications.

This meta-synthesis seeks to address this gap through an analysis of qualitative studies on ICU-to-ward transition. It aims to identify common themes and challenges while highlighting the areas in need of improvement in transition care. By integrating existing evidence and literature this study anticipates improving clinical practice and guiding future research. The ultimate goal is to smoothen the transition process, provide continuity of care to patients, and better outcomes for both patients and families.^4,5

Aims

The objective of this review is to identify, and synthesize the qualitative evidence regarding the experience of patients during transition from ICU to ward. This review was guided by two research questions: What are the emotional, informational, and support-related challenges faced by patients during the ICU-to-ward transition? and What evidence-based recommendations can be made to improve the transition process?

METHODS

Study design

A thematic synthesis was utilized to examine and integrate qualitative studies exploring patients' and caregivers' experiences during ICU transition. This synthesis involved detailed coding of the data at the line-by-line level, followed by developing descriptive themes and the identification of analytical themes.⁶ The review was conducted by the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guidelines, ensuring comprehensive and transparent reporting of the synthesis process.⁷

Search strategy

The search strategy involved systematically reviewing databases like PubMed, Cochrane Library, CINAHL, Embase, and Clinical Key to identify qualitative studies on patient experiences during the transition from ICU to ward. The search covered studies published between 2015 to 2024. Medical Subject Headings (MeSH) terms and keywords were used, including "qualitative studies," "transition," "hospital transition," "care coordination," and "patient experience." Boolean operators (AND, OR) were applied to refine and expand search results effectively.

The inclusion criteria were: studies focusing on patients aged 20 years and older, specially addressing ICU to general ward transition, only qualitative research studies. Studies that did not meet these inclusion criteria were excluded from the review. This strategy was designed to ensure a comprehensive selection of relevant literature for a thorough synthesis of patient experiences and insights for transition improvement.

Data extraction

First, duplicates from the retrieved literature were identified and removed. Then, the titles and abstracts of all studies were screened, followed by a full-text review of selected articles to confirm they met the inclusion criteria. Final data were extracted into an Excel spreadsheet, capturing key information such as author, publication year, study site, methodology, sample, and main findings. To ensure accuracy and minimize bias, two independent reviewers conducted the data extraction process. Any discrepancies between reviewers were resolved through discussion and consensus.

Quality appraisal

The quality of the included studies was assessed using the critical appraisal skills programme (CASP) qualitative research appraisal checklist. This checklist comprises 10 key criteria, each evaluated as 'yes', 'no', or 'unclear'. The studies were categorized into three quality levels: level A for full compliance with the appraisal criteria, indicating a low risk of bias; level B for partial compliance, suggesting a medium risk of bias; and level C for non-compliance, indicating a high risk of bias. Two reviewers independently assessed each study for quality, and any discrepancies between their assessments were resolved through discussion.

RESULTS

Search outcomes

The initial search identified 92 references. After screening the titles and abstracts, 72 references were retained for further evaluation. Following a full-text review and quality assessment, 10 studies were ultimately included in the meta-synthesis. Specific details regarding the screening process and reasons for exclusion are provided in Figure 1.

Characteristics of included studies

This meta-synthesis includes 10 qualitative studies that examine patients' and caregivers' experiences during the transition from the ICU to the general ward. The publication dates of these studies range from 2005 to 2023, with studies conducted in various countries, including the United Kingdom, South Korea, Sweden, Canada, Iran, Spain, and the Netherlands. The geographical distribution of the studies is as follows: two studies from South Korea two from Iran, two from the United Kingdom, and one study each from Canada, Spain, and the Netherlands.^9,10,12-17 Regarding ICU settings, the studies were conducted in a variety of ICU environments, including medical ICUs, surgical ICUs, and a combination of both. Some studies focused specifically on specialized ICUs, such as those for oncological patients or patients with specific critical conditions. Data collection took place in various settings: most studies were conducted in hospital wards or conference rooms, while some were also carried out in patients' homes, offering insights into the transition from both hospital and home perspectives. This diversity in data collection settings and geographical locations provides a rich context for understanding the experiences of both patients and caregivers during this critical transition period. In terms of ICU admission duration, studies varied in terms of the length of stay in the ICU. For instance, some studies focused on patients with shorter ICU stays, while others looked at those who had been admitted for longer periods. The sampling methods varied across studies, with six studies employing purposive sampling, while others used a combination of snowball sampling and cross-sectional methods.^9,12,13,15 The common data collection method was semi-structured interviews, although focus groups were also used in several studies to explore the collective experiences of caregivers and patients. A summary of the included studies is given in Table 1.

Quality appraisal of the included studies

The quality assessment of the included studies indicated that all 10 studies met the criteria outlined in the CASP critical appraisal checklist. The studies were evaluated based on their methodological rigor, relevance, and the validity of their findings. For a detailed breakdown of the quality assessment (Table 2).

Qualitative meta-synthesis

In the included studies, a total of 132 ICU patients and their caregivers were interviewed, resulting in the identification of 35 themes. A detailed verbatim analysis was conducted to extract concepts and codes from these themes. Themes were then combined based on their similarity and relevance, which allowed us to synthesize them into three primary themes: emotional adjustment, gaps in the transition process, deficient transition preparation, and recommendations for a smooth transition (Figure 2).

THEME 1- EMOTIONAL ADJUSTMENT

The first theme, emotional adjustment, captures the range of emotions experienced by ICU patients and their family caregivers when informed about the transition process. This theme encompasses three sub-themes: adaptation and resilience, highlighting their coping and adaptability; vulnerability and Uncertainty, reflecting fears and doubts about the transition; and psychosocial impact.

Adaptation and resilience

The sub-theme Adaptation and Resilience reflects the emotional strength and coping mechanisms that patients and caregivers develop as they transition from the ICU to a general ward.

"I feel relieved to leave the ICU. It's a heavy place to be. But I am still anxious about the ward because I am not under constant supervision anymore. I have to trust my body now".⁸

"It's overwhelming at first, but I know my partner is in good hands, and I've had to stay strong for them. We're taking it one step at a time".¹⁰

"The emotional support I get from my spouse has made all the difference. It's tough, but we're learning how to manage everything together".⁹

Vulnerability and uncertainty

The sub-theme vulnerability and uncertainty captures the emotional challenges that both patients and caregivers experience during the transition from the ICU to a general ward.

"I still feel weak and uncertain about my condition. The ICU was reassuring because there were always people around, but now I am not sure how things will progress".¹²

"I'm not sure what will happen next. There's a lot of uncertainty. I wish I could be with my loved one all the time, but I have to trust the staff in the ward now".¹³

"Even though I'm moving to a regular ward, I still feel like I'm in danger. There's always that thought in the back of my mind – what if something goes wrong?".¹¹

Psychosocial impact

The sub-theme psychosocial Impact explores the profound effects that the transition from the ICU to a general ward has on the mental and emotional well-being of both patients and their caregivers.

"The ICU was so intense, I felt like I was constantly under pressure. Now, moving to the ward, it's less hectic, but I still feel mentally drained and distant from everything. I feel like I'm not in control of my own body yet".¹⁴

"I'm mentally exhausted. I've been through so much watching my loved one in the ICU, and now moving to the ward doesn't make the worry go away. There are still so many unknowns. It's draining".¹⁶

"I feel disconnected from the world. It's like I'm not the same person I was before this illness. It's hard to come to terms with the changes in my body and my life".¹⁷

"Having my family around in the ward has helped me feel less isolated. It's still hard, but at least I'm not alone in it".⁹

THEME 2: GAPS IN THE TRANSITION PROCESS

This theme highlights the significant challenges patients and caregivers face during the transition from the ICU to the general ward. Many patients and their families reported feeling that the transition was marked by gaps in the process, which left them unprepared and uncertain. Three key sub-themes were identified: lack of resource access, limited decision-making involvement, and lack of caregiver recognition.

Lack of resource access

A significant challenge reported by both patients and caregivers during the transition from the ICU to the general ward is the lack of adequate access to resources.

"The transition felt abrupt. We didn't receive enough information on what to do after we left the ICU. It was like we were left to figure it all out on our own".¹⁰

"There were no clear instructions about follow-up care or emergency contacts. I felt completely unprepared once we left the ICU. It was stressful to try to figure out what to do next".¹³

"After the ICU, it felt like we were just sent out without much thought about what happens next. I wish there had been someone to guide us emotionally. There was no one to talk to about how to deal with all these feelings".⁹

"The doctor gave me a general explanation, but I didn't understand what was expected of me as a caregiver once we left the ICU. It would have helped if there had been a written guide or more information about caring for my spouse at home".¹²

"I felt like there was so much missing in terms of resources. It wasn't just the physical care needs; it was the emotional support that was lacking. I had no idea where to turn for help".¹⁴

Limited decision-making involvement

A key challenge identified by patients and caregivers during the ICU-to-ward transition was the lack of involvement in decision-making regarding the patient's care.

"The doctors made the decisions without really asking us what we thought. It was like they didn't consider our opinions or concerns, and that was frustrating".¹¹

In some cases, caregivers expressed feeling as though their role was limited to executing care rather than contributing to the decision-making process. This lack of shared decision-making left many feeling disengaged and unsure about how to best care for their loved ones after transitioning from the ICU.

"I didn't feel like I was part of the decisions. The healthcare team spoke mostly to the patient, and I was just following orders, not contributing to the conversation".¹⁶

"They told me I was being transferred to a general ward, but no one explained why or what it meant for me. I just had to go along with it, and I didn't have much say in the matter".¹² Caregivers also mentioned that they were often not consulted about the specifics of discharge plans or long-term care decisions, leading to a sense of neglect and a lack of preparation for the care demands they would face.

"When it came time for discharge, no one asked if I felt ready to take on the responsibility of caring for my spouse. It felt like they just decided for me".¹⁵

This lack of involvement in decision-making underscores the importance of including patients and caregivers in discussions about care planning, treatment options, and discharge decisions. Empowering them to participate in these decisions can lead to better outcomes and reduce the feelings of helplessness that many experienced during the transition process.

"It would have made such a difference if they had involved me more in the decisions. I would have felt more confident and prepared for the next steps".¹³

Lack of caregiver role recognition

Caregivers often felt overlooked by healthcare providers and were not acknowledged as active participants in the care team, despite their essential role in the patient's recovery and post-discharge care.

"I felt invisible. The doctors and nurses would talk directly to the patient, ignoring me even though I was the one providing the care at home. It was like they didn't realize how much I was doing".¹²

"They never asked me if I needed any help or if I had any concerns about the patient's care. It felt like they just focused on the patient without acknowledging that I was also part of this process".¹³

"I was never given proper training on how to care for my spouse after the ICU. They gave instructions to the patient, but what about me? I needed to know what to do too".¹¹

"When I tried to raise concerns, the healthcare team would often brush them off. They seemed to think I didn't know anything about the care, but I was the one spending the most time with the patient".¹⁶

"If I had been more involved and given more recognition, I would have felt more confident in caring for my loved one after discharge".¹⁷

THEME 3: DEFICIENT TRANSITION PREPARATION

The theme of deficient transition preparation reflects the significant gaps in ensuring that both patients and caregivers are properly prepared for the transition from the ICU to the general ward. Three sub-themes under this category are lack of care continuity, transition challenges, and institutional barriers.

Lack of care continuity

The lack of continuity in care is a major issue when patients are transferred from the ICU to the general ward. One patient shared, "In ICU, I had a consistent team who knew my history. In the ward, it was like I had to explain everything again, and they didn't seem to know about my recovery in the ICU".¹¹ Similarly, another caregiver mentioned, "They didn't explain anything to us. One day we were in the ICU, and the next we were in a new room with new doctors, and no one gave us an overview of what had been done".⁹

Transition challenges

The challenges during the transition itself are compounded by the lack of preparation, as patients and caregivers are not adequately informed about what to expect after the move from the ICU to the ward. One caregiver shared, "It was overwhelming, going from one team in the ICU to a whole new team on the ward. No one explained the changes that were happening".¹² Additionally, another caregiver reported, "We were told that things would get easier, but no one explained how the transition process would go. It felt like we were just dropped into a new world without support".¹⁷ This lack of clarity contributes to confusion, frustration, and increased emotional distress, making the transition period more difficult to manage.

Institutional barriers

Institutional barriers often prevent healthcare teams from fully preparing patients and caregivers for the ICU-to-ward transition. One healthcare provider explained, "In the ICU, we are focused on stabilizing the patient, and by the time they are ready for transfer, we don't have the resources to provide detailed handover or preparation for the ward".¹⁰ Another caregiver remarked, "It felt like the healthcare team was just trying to get through their day. I understand they are busy, but there should be a better system for preparing us for the next step".¹⁶

THEME 4: RECOMMENDATIONS FOR A SMOOTH TRANSITION

The theme recommendations for a smooth transition highlights the strategies and practices that can facilitate a more seamless and supportive transition from the ICU to the general ward. The studies suggest that improving communication, providing thorough patient and caregiver education, involving caregivers in decision-making, and ensuring continuity of care are crucial steps toward enhancing the transition process.

Improved communication and information sharing

A central recommendation for improving the transition process is enhancing communication between healthcare providers, patients, and caregivers. One patient stated, "I wish they had explained everything more clearly before the move. If I had known more about what to expect, I wouldn't have felt so lost when we arrived in the ward".¹³ Additionally, a caregiver shared, "Having a detailed conversation about what we could expect would have helped us prepare emotionally and mentally. We were left in the dark, and that was stressful".¹² These comments underscore the importance of proactive communication to ensure both patients and caregivers are well-informed.

Domains: 1-Clear statement of aims, 2-qualitative methodology suitability, 3-research design., 4-recruitment strategy, 5-data collection, 6-researcher-participant relationship, 7-ethical issues, 8-data analysis, 9-clear findings, and 10-value of research or interpretation of the data. Code: y-yes; n-no; u-unclear

Involvement of caregivers in decision-making

Another critical recommendation is to actively involve caregivers in decision-making during the transition process.

A caregiver shared, "I would have liked to be asked more about what I thought was best for my loved one. After all, I would be the one caring for them when they got home".¹⁷ Another caregiver mentioned, "I felt like I had no say in what happened next. If I had been more involved, I would have felt more confident in what I needed to do at home".¹⁶ These reflections suggest that empowering caregivers through involvement in decision-making can help improve care continuity and reduce feelings of helplessness.

Enhanced caregiver education and support

One caregiver highlighted, "We were given some instructions, but they were too general. I needed more hands-on training about what to do if something went wrong".¹¹ Another caregiver shared, "I felt completely unprepared to care for my loved one after discharge. I needed more guidance on how to manage their recovery at home".⁹ These comments underscore the importance of providing caregivers with the right tools, knowledge, and resources to confidently care for the patient after discharge.

Institutional support and resource allocation

Healthcare institutions should prioritize resources for discharge planning, invest in dedicated transition care teams, and ensure that both patients and caregivers have access to continuous support during and after the transfer. A healthcare professional noted, "Having a dedicated transition care team would make all the difference. We are often rushed and unable to provide the level of attention needed for patients moving from the ICU to the ward".¹⁰ Another patient remarked, "I think having a designated person to guide us through the transition process would have made the whole experience less overwhelming".¹⁷ These insights emphasize the need for systemic changes to support smoother transitions and better patient and caregiver outcomes.

DISCUSSION

The findings of this meta-synthesis reflect and expand the perspectives provided by previous research on ICU-to-ward transitions, highlighting the complex nature and vulnerability of this period for patients. There is a lot of emotional suffering during the ICU-to-ward move, according to several studies. In this regard, 2017 study discovered that patients often experience fear and anxiety when they visit the ward, mostly because they feel less monitored and supported.¹⁸ This is consistent with the latest research that found patients to feel hopeless and unsure about their path to recovery.

The findings of another study which noted that patients frequently feel unprepared and overwhelmed during transitions due to unclear or insufficient communication, are similarly in line with the communication gaps revealed in this synthesis.¹⁹ By the meta-synthesis's recommendation to use standardized education and communication strategies to increase patient readiness and confidence, their study emphasized the importance of systematic discharge education programs. This synthesis underlines a significant problem that has also been identified in previous research: the lower staff-to-patient ratios in the general ward in contrast to the critical care unit. In light of ward staff's inability to provide them with the same degree of attention as intensive care unit (ICU) staff, patients who left the ICU frequently complained of receiving inadequate care.²⁰ The findings emphasize the need for transitional care models, such as those described in 2018 involving the use of specialized transition nurses to fill the gap and offer reliable care during this difficult period.²¹

The significance of comprehending patients' lived experiences throughout transitions to informed care practices has been underlined by qualitative research like those conducted in 2021.²² Their research supported the findings of this meta-synthesis by identifying related themes of emotional vulnerability and unfulfilled informational requirements.

Furthermore, another study emphasized the importance of patient-centered interventions that support the suggestions made in this study for enhancing ICU-to-ward transitions, such as pre-transition counselling and customized follow-up care.²³

This synthesis highlights the scattered nature of current research despite these alignments. Although several facets of the ICU-to-ward transition have been examined in individual research, few have combined these results into an all-encompassing paradigm. By combining various qualitative observations, this meta-synthesis fills that knowledge gap and offers an in-depth understanding of the difficulties and experiences of patients throughout this crucial stage.

CONCLUSION

Current review shows challenges and experiences patients and families faces during the ICU to ward transition. Improving ICU discharge process requires a standardized transition guidelines including patient and caregivers formal training and education, facilitate good communication during transition and continue post transition follow up with the patients and family. These findings should be expanded upon in future studies to create and evaluate responsive therapies.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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