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The Patient and Family Perioperative Experience During Transfer of Care: A Qualitative Inquiry
The Patient and Family Perioperative Experience During Transfer of Care: A Qualitative Inquiry SONJA E. STUTZMAN, PhD; DAIWAI M. OLSON, PhD, RN, CCRN, FNCS; PHILIP E. GREILICH, MD; KAMAL ABDULKADIR, BSN, RN; MICHAEL A. RUBIN, MD, MA
ABSTRACT Patient transfers between the OR and intensive care unit are high-risk events. Previous studies regarding mechanisms to improve these transfers do not account for the perspectives of family members or patients. Using transfer-of-care reports from health care providers, we performed a qualitative study of patient and family member perspectives by transcribing, coding, and analyzing seven interviews using hermeneutic cycling, which revealed three main themes: communication, clinical interaction, and clinician demeanor. Participants reported that anxiety about the plan of care and its outcomes eased when they had more frequent communication with members of the clinical team, observed the team interacting with one another, and felt the clinicians’ demeanors were confident. The results of this study showed that families perceived that clinicians who communicated the timing and frequency of protocols and procedures improved patient care. Clinician training on empathy, professionalism, and accessibility may increase patient and family satisfaction and decrease negative interactions between clinicians and patients and their family members. AORN J 105 (February 2017) 193-202. ª AORN, Inc, 2017. http://dx.doi.org/10.1016/j.aorn.2016.12.006 Key words: patient transfer, transfer of care, hand-over communication, patient-centered care, qualitative research.
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ransfers of care (TOCs) between surgical and intensive care staff members are largely unstructured events that do not always follow a specific 1 order. An efficient TOC of a patient from the OR to the intensive care unit (ICU) is critical to reduce medical error.1 These TOCs are also known as hand overs or hand offs. The volume, pace, and unstructured format of the information shared during this time can be associated with miscommunication and increased error rates in health care delivery.1 Patient-centered research shows a growing emphasis on providing a TOC report to patients and their family members;
however, to date, this focus has been inadequate.2 Historically, researchers have explored the TOC from the perspectives of the sender (eg, RN circulator, surgeon, anesthesia professional) and the receiver (eg, ICU team members) and have not studied patient and family member perspectives.3 Care providers may assume that family members will not understand or are not concerned with receiving a TOC report; however, patient-centered research raises doubts about these assumptions.4 Our qualitative inquiry explored the experiences of patients and their families after TOC from the OR to the ICU. We used a qualitative study methodology to identify important patient and family perspectives regarding the TOC.
http://dx.doi.org/10.1016/j.aorn.2016.12.006 ª AORN, Inc, 2017
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LITERATURE REVIEW Communication between treatment teams during the caregiver-to-caregiver TOC has been classified as a high-risk event.5,6 Communication failures related to hospitalized patients are associated with treatment delays, diagnostic delays, failure to follow the plan of care, adverse events, patient dissatisfaction, and increased length of stay.5,7,8 In 2006, The Joint Commission identified standardized TOC communication as a patient safety goal.9 In 2008, The Joint Commission identified critical steps, procedures, and processes to decrease defective hand overs by 50%.10 Additionally, The Joint Commission identified that effective hand overs improve patient, family, and staff member satisfaction.10 Critically ill patients who are transferred between the OR and the ICU are an especially vulnerable population, and a lack of patient care continuity for this population can result in adverse events.1 Studies show the Situation, Background, Assessment, Recommendation (SBAR) technique to be an effective method of information transfer. The SBAR technique may help in increasing the strength of communication in health care settings.3,11 Crucial to patient error reduction is the consistency, thoroughness, and efficiency of the caregiver-to-caregiver TOC.6 Zavalkoff et al8 introduced a TOC tool for use when pediatric patients are transferred from the OR to the pediatric ICU. The tool included four major information sections:
preoperative status, medical intraoperative status, surgical intraoperative status, and immediate postoperative status.8
The study demonstrated that the tool resulted in a more thorough TOC and was associated with a reduction of communication-related high-risk events.8 Although some data show a reduction in high-risk events post transfer when clinicians use a transfer tool, few research studies have explored the perceived discrepancies when the patient and his or her family are considered.12 Models of patient care have been transitioning to a more collaborative approach since the early 2000s.4 Results from one study show that the use of collaborative decision making (eg, shared decision making between all providers, the patient, and the family members) by staff members in ICUs is correlated with improved patient outcomes and patient satisfaction.4 One representative description of this paradigm is the collaborative autonomy model for shared decision making, in which patients and family members have increased input in treatment planning and more access to the clinical team.4
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Research regarding patient and family perspectives of the TOC report provided to them after transfer from the OR to ICU are scarce in the literature. Although these perspectives can be gathered through self-reported questionnaires, there are several other avenues that can add to understanding the perspectives of patients and family members. Qualitative research is one way to better understand the experiences that people are exposed to during a particular process or phenomenon.13,14 In 2015, McElroy et al2 published a qualitative study of clinicians’ perceptions of patient TOC from the OR to ICU. Their findings demonstrated that communication and teamwork among clinicians is key to a successful TOC.2 Although this study provides some helpful insights about caregiver-tocaregiver TOCs, a more holistic approach to improving the caregiver-to-patient or -to-family-member TOC process requires a similar qualitative analysis of their perspectives. Groups that support research (eg, National Institutes of Health, Agency for Healthcare Research and Quality, Patient-Centered Outcomes Research Initiative) are emphasizing the importance of patient experiences in research. Most TOC research has centered on care providers and reducing medical errors through improved protocols, not patient and family experiences.1,2,15,16 Our study team aimed to better understand the patient and family perspectives about their TOC experience by asking open-ended questions about their experience and their preferences during these transfers, a novel area of investigation that can inform future quantitative research.
METHODS We used opportunistic sampling in this study. We recruited patients and family members experiencing a perioperative event that would result in a transfer to the ICU who consented to partake in a single, semistructured interview.
Description of Study Design Our research was approved by the institutional review board at the University of Texas Southwestern Medical Center, Dallas; all interviews took place in the ICU. We collected, transcribed, coded, and analyzed the data using hermeneutic cycling. The purpose of hermeneutic cycling is to add knowledge based on interpretations and understanding of a specific phenomenon or experience. The members of our research team have prior experience in qualitative research, and the primary researcher has a background in psychology and qualitative research methods. This background aided the research team in better understanding the systemic effect of the patient and family member TOC process. The primary researcher used the
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hermeneutic cycling method to guide the data analysis and interpretation of this study (Figure 1).17,18
Sampling Technique and Procedures Opportunistic sampling with an open recruitment period is a validated technique for qualitative research.19 Opportunistic sampling involves following leads provided by clinical staff members and taking advantage of the events throughout the clinical process that align to allow participants to be eligible in the study.20 Participants verbally consented to the study. We identified eligible participants who were adult patients (aged 18 or older) o scheduled for a surgical procedure with a planned ICU admission and o transferred directly to the ICU after the surgical procedure, or adult family members of a patient who underwent OR-toICU transfer. After the surgical procedure, the researchers collaborated with the ICU clinical team to determine whether the patient had the cognitive ability to understand the consent and provide his or her written consent and to understand the study questions. If so, the researcher conducted the interview with the patient. If the patient was not cognitively competent, the researcher approached the patient’s family members about participating in the study. The institutional review board approved the verbal consent process. Under the verbal consent approval, the study team did not collect data on who was interviewed or any identifying information of those involved in the interview, including whether it was the patient or a family member. We conducted seven face-to-face interviews. The semi-structured interviews (Table 1) occurred in the patient’s room, the ICU waiting room, or a private conference room located near the ICU. We conducted the interviews with the patient only, patient and family members, or family members only. Although the researchers did not collect data regarding who was in each interview, we inferred this information from the interview to determine whether the patient or the family member was speaking (eg, “she” went to the OR versus “I” went to the OR). After the first three of the seven interviews, our team discussed the original questions and follow-up questions to consider for interviews with the remaining eligible participants (Table 2). We then compiled these questions into a second document that was taken to the remaining interviewees as a reference for follow-up questioning. We continued the interview with each participant until the two primary researchers felt that data
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Figure 1. Primary research interpretation of hermeneutic cycling to guide the research process. Adapted with permission from the University of Texas Southwestern Medical Center, Dallas. saturation had been achieved. Each patient or family member was interviewed once.
Rigor We addressed rigor through peer review; through triangulation of various sources of data including patient interviews, family interviews, and review of literature; and by maximizing variation. Peer review is the act of having another colleague read and comment on the transcript and findings, and it addresses the confirmability criterion of judging qualitative research.13,14,21 Two faculty-level peer reviewers appraised four of the seven interviews and read two assigned interviews each. Each peer reviewer made note of important quotations and potential themes and subthemes for each interview. We discussed the findings from our peer reviewers’ analyses with our main coder. Peer reviewers and the main coder interpreted the themes in a similar manner. Triangulation is the process of using multiple methods to confirm findings, and it addresses the dependability criterion AORN Journal j 195
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for judging qualitative research.21 The triangulation of multiple resources (ie, patient interviews, family interviews, review of the literature) helped to support the themes uncovered in participant responses (ie, communication, clinical interaction, clinician demeanor). In many circumstances, the process of triangulation encouraged a reframing of the content in the interview and, by providing additional reference points, bolstered our understanding of how participants or their families experienced the TOC and why.
patient’s family and the timing of that communication in easing fear. Family members and patients identified communication as an essential part of the TOC. For example, a patient from the sixth interview shared the following perspective regarding clinical team communication with him and his family:
Maximizing variation is the process of selecting a diverse sample and judges’ data for transferability.21 In this study, we conducted all interviews at an urban hospital, but many of the participants had been transferred to this hospital from smaller rural hospitals for their procedure. Additionally, we collected data during a period of approximately five months, which supported variation in clinicians involved in the care of the patients. Access to participants was limited by the window of opportunity to approach families for participation.
Preoperative communication
DATA ANALYSIS Members of the institutional review boardeapproved research team completed verbatim transcription after each interview. We used hermeneutic cycling as the basis for coding. Our primary investigator coded all seven interviews, which involved reading the transcript a minimum of three times. The first reading was to understand the transcript and highlight important points. The second reading identified specific codes. Codes included designations for important statements, ideas, or quotes that were portrayed in each interview. The third reading was to organize, or clump, codes with similar meaning or topics into groups to identify themes. After a third reading, the primary investigator transferred the codes to notecards to organize support for each of the identified themes. Next, we diagrammed the themes by using color-coded representations of themes, subthemes, and codes for each interview (Figure 2; figure was modified from its original version to adhere to AORN Journal style). This process was completed for each interview, and after all interviews were conducted, we diagrammed themes for all to show crossinterview themes. The aggregation of codes to specific clusters allowed us to identify the themes for this study.5
RESULTS We found three main themes in this study: communication, clinical interaction, and clinician demeanor (Figure 3).
Communication The most prominent theme that surfaced in every interview was the importance of communication with the patient and the 196 j AORN Journal
They told us everything from the beginning to the end. What they were going to do, how they were going to do it, what to expect, the pros, cons, good, bad.
Communication with the OR clinical team often began before hospitalization. When both the nurse and the physician communicated with the patient before the procedure, patients and their family members reported less anxiety regarding the procedure. In the hospital, patients reported that they would like to see the surgeon before the procedure. Patients also mentioned that if they had seen or talked to the perioperative nurse before the surgical procedure, they felt more at ease.
Intraoperative communication During the surgical procedure, communication with the family was pivotal, especially regarding the length of the surgical procedure. Surgeons often provided an estimated time for completing the procedure, and as the estimated time of completion neared, family members reported growing more anxious. Most reported they would like to hear something about how the surgical procedure was progressing from a member of the OR team. If the estimated time passed with no report, family members reported greater anxiety and wished they could have heard from a member of the care team. One family member stated: The surgery [was] supposed to be done around 2:20 . . . if someone had physically come out and said, ‘everything is good, I know it’s going into a little further than what we first told you, so I just wanted to let you know that everything is good.’ [Participant did not complete statement]. Family members reported that they specifically liked hearing from the surgeon rather than other team members after the surgical procedure because they perceived the surgeon as the leader and “most in charge.” Family members reported that they liked to hear an estimated time after which they would be able to see the patient and a time at which the patient would return to the ICU. The specific topic of communication was also a subtheme that varied across individuals. Topics that were important included explaining what is happening (eg, why it is taking longer than expected, what steps are involved in the surgical procedure),
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Table 1. Semistructured Interview Questions When you think about the OR staff members communicating with the intensive care unit (ICU) staff members, what are the most important types of information that you want shared? Why is it important to you personally that the OR staff members communicate directly with the ICU staff members after your surgery? What are the most important things that you will tell the OR staff members, which you want communicated to the ICU staff members? Have you ever had surgery before? If YES: How could we improve the transfer of care so that you get better care? If NO: What types of information are you most worried about being communicated to the ICU staff members? Adapted with permission from the University of Texas Southwestern Medical Center, Dallas.
medications, patient condition, changes in condition, and what to expect in the short term. It became clear in the interviews that each patient and his or her family members had expectations of what they wanted the clinical team to discuss. Although consistent themes were demonstrated, participants tended to emphasize one particular priority over others. One family member discussed being part of a care plan meeting as an important way to understand clinical decision making: I heard how they weigh things out when there’s a team of doctors and I thought, wow, that would be nice to know. Why can’t I sit in on that . . . maybe they should have a premeeting and come to their conclusion and then have me come in? The family member reflected that it was important for her to hear the physicians “weigh things” by discussing the plan of action for her son’s care. Additionally, the premeeting she refers to may have involved shared decision making between her, her son (ie, the patient), and the clinical team before any care plan decisions were enacted. Table 2. Supplemental Follow-Up Questions Who would you like to communicate with? When would you like to communicate with each member of the team (eg, nurse, intensive care unit [ICU] physician, surgeon)? Have you observed any interactions or communication between the team members of the ICU and OR? Do you feel this communication was adequate? How were you prepared for the surgery? What expectations did you have for the surgery and transfers of care after your surgery? Adapted with permission from the University of Texas Southwestern Medical Center, Dallas.
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The last aspect of communication concerns frequency and quantity rather than quality. This aspect overlaps with the second theme, clinical interaction. The more the families observed the care teams communicating with each other, the more they were at ease. Therefore, if families are able to observe the OR team and the ICU team discussing the patient’s care, it may put the family at ease.
Clinical Interaction The second theme was clinical interaction, which was supported by two subthemes: nurse-to-nurse communication and visible team interaction. Clinical interaction refers to the specific discussions that occurred in and between the ICU and OR teams. Of note, neither physician-to-nurse nor physicianto-physician communication emerged as a specific subtheme. However, nurse-to-nurse communication was especially important for the family to witness during the transfer. For example, the patient in interview seven reported observing the nursing team discussing medication and physiologic changes (eg, blood pressure) during the transfer; this observation eased his concerns. The participant in interview four noted, “. . . [nurses] talked to each other. They were detailed.” She reported that this observation eased her postoperative anxiety. Communication about upcoming postoperative testing (eg, computed tomography scans) was important for family members to receive so that they knew what to expect and could make scheduling or visitation changes as needed. Another patient’s family member felt that both the OR and ICU team knew everything that happened to the patient, which led to the patient’s family member feeling safe. She stated, There’s a whole bunch of important information that isn’t communicated to us, but each other [clinicians]deverything that happened . . . they know what they’re looking for. AORN Journal j 197
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Figure 2. Supplemental digital material example of coding for a single interview. Adapted with permission from the University of Texas Southwestern Medical Center, Dallas.
The family members in this interview understood that they did not need to know all of the details of the medical care, but they wanted to know that the clinicians were knowledgeable about the patient when he or she was transferred from the OR to ICU. The second subtheme was visible team interaction. A better understanding of the responsibilities and roles of each team member better equipped family members to ask certain questions of each team member. As one patient explained, “Make sure everyone knows the chain of custody.” Another reported that he felt like a football team was around him during his transfer and this led to him feeling safe. A different patient’s family member recounted seeing the OR team in the ICU: “They all came . . . and they’re all business.” The family also agreed that seeing both teams during the transfer helped ease their worry, because they could see all members of the team communicating and caring for the patient. Increased visibility of the team may have lessened the family’s concern. 198 j AORN Journal
Clinician Demeanor The third theme was clinician demeanor toward the patient and family, which was supported by the subthemes of accountability and accessibility. For example, one individual commented, “We talked to the nurse that was in the operating room, and she told us how long she’d been doing this. She loves her job.” Interpretations of clinician demeanor were coded independently from clinical interactions, and the themes were supported by different codes. Interactions with other team members are observations of communication; demeanor is the outward behavior toward the patient and his or her family member. As one family member reported, “People were confident in their position.” The confidence this family member is referring to may be interpreted as the clinicians understanding their roles, being knowledgeable about patient details, and understanding the patient’s plan of care during the transition from the OR to the ICU.
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Figure 3. Inter-interview themes and subthemes. Adapted with permission from the University of Texas Southwestern Medical Center, Dallas. The patients and family members reported the effect of preoperative communication about what patients and families can expect. One patient reported, “He’s really good about letting people know the adventure they’re going to be on.” This comment referred specifically to the surgeon’s communication with her about the surgical procedures. The clinicians who provided open and honest communication about the procedure (eg, explaining expected and unexpected issues that occurred during the procedure and the postprocedure transfer) were perceived as more confident and decreased family and patient worry during the transfer from the OR to the ICU. The patients and families reported a desire for the following two items: access to the physician and accountability from the nurse. For participants, this meant they expected the nurse to follow through or follow up with them. Those patients and families who felt the physician was accessible (eg, preoperative phone calls, discussions with the surgeon immediately before the surgical procedure, talking to the surgeon immediately after the surgical procedure) were the patients and families who were most at ease. The patient in interview two mentioned the following exchange: The doctor called me personally . . . and said he looked it all over and said he wants “Dr Adam” to do the procedure. He made the phone call. I thought that was really good, you know, I heard from the doctor. The patient in interview seven also reported the importance of clinician accessibility: My wife and I have been highly impressed with [the surgeon’s] personableness and his demeanor and his willingness to take as much time as needed to answer questions and give us information about the situation. Accountability, the second subtheme, was directed toward nurses. The family wanted to be able to ask the ICU nurse
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about the patient and his or her care in the OR. Moreover, there was a sense that families wanted the nurse to be available, to know and understand the details about the patient (eg, blood pressure, heart rate, medications), and to know the answers to the families’ questions or know who to ask for the answers. For one family, accountability during a complication that occurred as the patient reached the ICU was especially important: They didn’t come out and tell us they were doing anything . . . maybe the doctor changed his mind after he talked to us . . . We waited for two or three hours, and there were complications. All we knew is we couldn’t go back there [to the ICU], and we all took turns asking if we could go back. This situation provides evidence of the critical and unstable state of a patient when being transferred from the OR to the ICU. The patient is the priority in these situations. An important team approach to lessen family stress of the unknown is to have a fellow team member report information to the family. In general, if the family members were able to receive answers regarding patient status, they reported experiencing less stress.
DISCUSSION The TOC can be a stressful time for patients, family members, and clinicians.2,3 Furthermore, the period before and after the TOC has been identified as a high-risk time for errors to occur. Researchers and clinicians agree that communication is essential and may improve patient outcomes, which is not surprising and supports literature on the importance of involving the patient and his or her family in decision making.4 The novelty of this study is its emphasis on how communication with patients and their families occurs during high-stress TOCs and the highlighting of the timing and topic of the information communicated.4
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Family members in our study believed communication should begin before hospitalization and continue through the surgical procedure to the postoperative period and be more inclusive. The topic of the conversation also was important. Some family members emphasized the importance of communicating physiologic changes; others simply wanted to know whom to speak with and how to get answers about the patient. One participant suggested a family team meeting before the procedure to meet the assigned clinical team members and to talk about specific concerns (ie, physiologic changes versus discharge information). Roter et al22 reported that nonverbal communication (eg, clinical demeanor) was as important as verbal. Nonverbal communication plays a large role in the way we understand others, and it has also been shown to affect patient outcomes.22 Clinicians who appeared to be empathetic, caring, available, and concerned were highly regarded. Patients and family members reported that these positive types of demeanor eased their anxiety. In general, research has shown that verbal and nonverbal communication with patients and families is important.23 Indicators of positive communication in specific hospital experiences (eg, TOC) are crucial to understand in the context of the patient’s, family members’, and clinicians’ experiences.
LIMITATIONS The nature of our study was qualitative, which presents a unique opportunity to understand a specific aspect of a problem. Qualitative research also lends itself to hypothesis generation for future research. Our study involved only seven interviews and thus is not indicative of the experiences or opinions of all surgical patients or the TOC process. Although there are strengths to qualitative methodology, the results may not be generalized to varying populations and locations. Our study used two interviewers, which made interviews more inconsistent, and some information may have been missed in certain interviews. The interviewers have varying backgrounds, and thus presented distinctly to the patients and families, which added to the richness of the data collected. We conducted the interviews during a stressful time, and therefore the responses of the patients and their families may have been skewed by the setting of the interview. This factor could also be seen as strength, because the researchers were able to capture unique data during this important time frame. 200 j AORN Journal
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CLINICAL PRACTICE RECOMMENDATIONS This study has several clinical implications. First, it supports the idea that communication with the patient and his or her family is important. Specifically, communication with the patient and family before and during the surgical procedure was endorsed in multiple interviews. We found that it was particularly helpful for both the patient and the family members to see the perioperative nurse and the surgeon before the procedure. The families reported wanting to communicate during the procedures, especially prolonged procedures and those in which duration exceeded initial time expectations. Immediately after the procedure, it was helpful for the family to communicate with the surgeon. The family also reported wanting to know specifically when and where they could see their family member. In the ICU, it was important for the patient and the family members to observe the OR and ICU RNs communicating about the specific status and physiologic changes of the patient. It was also important for the family members to be able to ask the ICU RN questions regularly after the TOC. The themes extracted from this study supported a sit-down meeting and a checklist (for the patient’s family to complete) as a pathway to the topics and type of desired communication with the clinical team. This checklist would allow patients and families to decide which staff member (eg, perioperative nurse, ICU nurse, surgeon, anesthesia professional, critical care physician) is most appropriate to communicate with the family, the timing of communication (ie, before, during, or after the surgical procedure and TOC), and the topics the family would like to discuss (eg, an overall discussion of the patient’s general well-being, specific physiologic factors). Clinicians may lack training on how demeanor affects patients’ families, but it is very important to patients and their families and should be something that is considered (eg, a calm, attentive demeanor promotes a calm patient or family). When possible during preoperative patient interviews, the clinical team can assist in preparing the surgeon with background about family dynamics, family wants and needs, and information that family members would like to have. The preparation could also be provided to the surgeon in a handout or checklist to prepare the surgeon to deliver desired information to the family.
CONCLUSION Our study has implications for all clinical team members caring for critically ill patients. The TOC from the OR to the
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ICU occurs in the last few moments before the family and patient are reunited after the surgical procedure; therefore, this time is full of anxiety for the family and patient. Easing tension and anxiety is an important part of clinical care. Structured time and handouts may be one manner in which the TOC can be standardized to meet the needs of the patient, family members, and clinical teams in an efficient manner. Future studies are needed to test these potential avenues of communication during the TOC. Themes may include whom the patient wishes to speak with, timing of communication, and topics. Interventions should be developed and prospectively tested to address each of the communication themes and subthemes.
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Sonja E. Stutzman, PhD, is a clinical research coordinator in the Department of Neurology and Neurotherapeutics at the University of Texas Southwestern Medical Center, Dallas. Dr Stutzman has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
DaiWai M. Olson, PhD, RN, CCRN, FNCS, is an associate professor in the Department of Neurology and Neurotherapeutics and the Department of Neurosurgery at the University of Texas Southwestern Medical Center, Dallas. As the editor-in-chief for the Journal of Neuroscience Nursing, Dr Olson has declared an affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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Philip E. Greilich, MD, is a professor in the Department of Anesthesiology and Pain Management at the University of Texas Southwestern Medical Center, Dallas. As the recipient of a grant from the University Hospital, San Antonio, TX, Dr Greilich has declared an affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Kamal Abdulkadir, BSN, RN, is a bedside nurse in the neurointensive care unit at Zale Lipshy University Hospital in the University of Texas Southwestern Medical Center, Dallas. As the recipient of a grant from
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Michael A. Rubin, MD, MA, is an assistant professor in the Department of Neurology and Neurotherapeutics and Department of Neurosurgery at the University of Texas Southwestern Medical Center, Dallas. Dr Rubin has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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ABSTRACT Patient transfers between the OR and intensive care unit are high-risk events. Previous studies regarding mechanisms to improve these transfers do not account for the perspectives of family members or patients. Using transfer-of-care reports from health care providers, we performed a qualitative study of patient and family member perspectives by transcribing, coding, and analyzing seven interviews using hermeneutic cycling, which revealed three main themes: communication, clinical interaction, and clinician demeanor. Participants reported that anxiety about the plan of care and its outcomes eased when they had more frequent communication with members of the clinical team, observed the team interacting with one another, and felt the clinicians’ demeanors were confident. The results of this study showed that families perceived that clinicians who communicated the timing and frequency of protocols and procedures improved patient care. Clinician training on empathy, professionalism, and accessibility may increase patient and family satisfaction and decrease negative interactions between clinicians and patients and their family members. AORN J 105 (February 2017) 193-202. ª AORN, Inc, 2017. http://dx.doi.org/10.1016/j.aorn.2016.12.006 Key words: patient transfer, transfer of care, hand-over communication, patient-centered care, qualitative research.
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ransfers of care (TOCs) between surgical and intensive care staff members are largely unstructured events that do not always follow a specific 1 order. An efficient TOC of a patient from the OR to the intensive care unit (ICU) is critical to reduce medical error.1 These TOCs are also known as hand overs or hand offs. The volume, pace, and unstructured format of the information shared during this time can be associated with miscommunication and increased error rates in health care delivery.1 Patient-centered research shows a growing emphasis on providing a TOC report to patients and their family members;
however, to date, this focus has been inadequate.2 Historically, researchers have explored the TOC from the perspectives of the sender (eg, RN circulator, surgeon, anesthesia professional) and the receiver (eg, ICU team members) and have not studied patient and family member perspectives.3 Care providers may assume that family members will not understand or are not concerned with receiving a TOC report; however, patient-centered research raises doubts about these assumptions.4 Our qualitative inquiry explored the experiences of patients and their families after TOC from the OR to the ICU. We used a qualitative study methodology to identify important patient and family perspectives regarding the TOC.
http://dx.doi.org/10.1016/j.aorn.2016.12.006 ª AORN, Inc, 2017
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LITERATURE REVIEW Communication between treatment teams during the caregiver-to-caregiver TOC has been classified as a high-risk event.5,6 Communication failures related to hospitalized patients are associated with treatment delays, diagnostic delays, failure to follow the plan of care, adverse events, patient dissatisfaction, and increased length of stay.5,7,8 In 2006, The Joint Commission identified standardized TOC communication as a patient safety goal.9 In 2008, The Joint Commission identified critical steps, procedures, and processes to decrease defective hand overs by 50%.10 Additionally, The Joint Commission identified that effective hand overs improve patient, family, and staff member satisfaction.10 Critically ill patients who are transferred between the OR and the ICU are an especially vulnerable population, and a lack of patient care continuity for this population can result in adverse events.1 Studies show the Situation, Background, Assessment, Recommendation (SBAR) technique to be an effective method of information transfer. The SBAR technique may help in increasing the strength of communication in health care settings.3,11 Crucial to patient error reduction is the consistency, thoroughness, and efficiency of the caregiver-to-caregiver TOC.6 Zavalkoff et al8 introduced a TOC tool for use when pediatric patients are transferred from the OR to the pediatric ICU. The tool included four major information sections:
preoperative status, medical intraoperative status, surgical intraoperative status, and immediate postoperative status.8
The study demonstrated that the tool resulted in a more thorough TOC and was associated with a reduction of communication-related high-risk events.8 Although some data show a reduction in high-risk events post transfer when clinicians use a transfer tool, few research studies have explored the perceived discrepancies when the patient and his or her family are considered.12 Models of patient care have been transitioning to a more collaborative approach since the early 2000s.4 Results from one study show that the use of collaborative decision making (eg, shared decision making between all providers, the patient, and the family members) by staff members in ICUs is correlated with improved patient outcomes and patient satisfaction.4 One representative description of this paradigm is the collaborative autonomy model for shared decision making, in which patients and family members have increased input in treatment planning and more access to the clinical team.4
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Research regarding patient and family perspectives of the TOC report provided to them after transfer from the OR to ICU are scarce in the literature. Although these perspectives can be gathered through self-reported questionnaires, there are several other avenues that can add to understanding the perspectives of patients and family members. Qualitative research is one way to better understand the experiences that people are exposed to during a particular process or phenomenon.13,14 In 2015, McElroy et al2 published a qualitative study of clinicians’ perceptions of patient TOC from the OR to ICU. Their findings demonstrated that communication and teamwork among clinicians is key to a successful TOC.2 Although this study provides some helpful insights about caregiver-tocaregiver TOCs, a more holistic approach to improving the caregiver-to-patient or -to-family-member TOC process requires a similar qualitative analysis of their perspectives. Groups that support research (eg, National Institutes of Health, Agency for Healthcare Research and Quality, Patient-Centered Outcomes Research Initiative) are emphasizing the importance of patient experiences in research. Most TOC research has centered on care providers and reducing medical errors through improved protocols, not patient and family experiences.1,2,15,16 Our study team aimed to better understand the patient and family perspectives about their TOC experience by asking open-ended questions about their experience and their preferences during these transfers, a novel area of investigation that can inform future quantitative research.
METHODS We used opportunistic sampling in this study. We recruited patients and family members experiencing a perioperative event that would result in a transfer to the ICU who consented to partake in a single, semistructured interview.
Description of Study Design Our research was approved by the institutional review board at the University of Texas Southwestern Medical Center, Dallas; all interviews took place in the ICU. We collected, transcribed, coded, and analyzed the data using hermeneutic cycling. The purpose of hermeneutic cycling is to add knowledge based on interpretations and understanding of a specific phenomenon or experience. The members of our research team have prior experience in qualitative research, and the primary researcher has a background in psychology and qualitative research methods. This background aided the research team in better understanding the systemic effect of the patient and family member TOC process. The primary researcher used the
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hermeneutic cycling method to guide the data analysis and interpretation of this study (Figure 1).17,18
Sampling Technique and Procedures Opportunistic sampling with an open recruitment period is a validated technique for qualitative research.19 Opportunistic sampling involves following leads provided by clinical staff members and taking advantage of the events throughout the clinical process that align to allow participants to be eligible in the study.20 Participants verbally consented to the study. We identified eligible participants who were adult patients (aged 18 or older) o scheduled for a surgical procedure with a planned ICU admission and o transferred directly to the ICU after the surgical procedure, or adult family members of a patient who underwent OR-toICU transfer. After the surgical procedure, the researchers collaborated with the ICU clinical team to determine whether the patient had the cognitive ability to understand the consent and provide his or her written consent and to understand the study questions. If so, the researcher conducted the interview with the patient. If the patient was not cognitively competent, the researcher approached the patient’s family members about participating in the study. The institutional review board approved the verbal consent process. Under the verbal consent approval, the study team did not collect data on who was interviewed or any identifying information of those involved in the interview, including whether it was the patient or a family member. We conducted seven face-to-face interviews. The semi-structured interviews (Table 1) occurred in the patient’s room, the ICU waiting room, or a private conference room located near the ICU. We conducted the interviews with the patient only, patient and family members, or family members only. Although the researchers did not collect data regarding who was in each interview, we inferred this information from the interview to determine whether the patient or the family member was speaking (eg, “she” went to the OR versus “I” went to the OR). After the first three of the seven interviews, our team discussed the original questions and follow-up questions to consider for interviews with the remaining eligible participants (Table 2). We then compiled these questions into a second document that was taken to the remaining interviewees as a reference for follow-up questioning. We continued the interview with each participant until the two primary researchers felt that data
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Figure 1. Primary research interpretation of hermeneutic cycling to guide the research process. Adapted with permission from the University of Texas Southwestern Medical Center, Dallas. saturation had been achieved. Each patient or family member was interviewed once.
Rigor We addressed rigor through peer review; through triangulation of various sources of data including patient interviews, family interviews, and review of literature; and by maximizing variation. Peer review is the act of having another colleague read and comment on the transcript and findings, and it addresses the confirmability criterion of judging qualitative research.13,14,21 Two faculty-level peer reviewers appraised four of the seven interviews and read two assigned interviews each. Each peer reviewer made note of important quotations and potential themes and subthemes for each interview. We discussed the findings from our peer reviewers’ analyses with our main coder. Peer reviewers and the main coder interpreted the themes in a similar manner. Triangulation is the process of using multiple methods to confirm findings, and it addresses the dependability criterion AORN Journal j 195
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for judging qualitative research.21 The triangulation of multiple resources (ie, patient interviews, family interviews, review of the literature) helped to support the themes uncovered in participant responses (ie, communication, clinical interaction, clinician demeanor). In many circumstances, the process of triangulation encouraged a reframing of the content in the interview and, by providing additional reference points, bolstered our understanding of how participants or their families experienced the TOC and why.
patient’s family and the timing of that communication in easing fear. Family members and patients identified communication as an essential part of the TOC. For example, a patient from the sixth interview shared the following perspective regarding clinical team communication with him and his family:
Maximizing variation is the process of selecting a diverse sample and judges’ data for transferability.21 In this study, we conducted all interviews at an urban hospital, but many of the participants had been transferred to this hospital from smaller rural hospitals for their procedure. Additionally, we collected data during a period of approximately five months, which supported variation in clinicians involved in the care of the patients. Access to participants was limited by the window of opportunity to approach families for participation.
Preoperative communication
DATA ANALYSIS Members of the institutional review boardeapproved research team completed verbatim transcription after each interview. We used hermeneutic cycling as the basis for coding. Our primary investigator coded all seven interviews, which involved reading the transcript a minimum of three times. The first reading was to understand the transcript and highlight important points. The second reading identified specific codes. Codes included designations for important statements, ideas, or quotes that were portrayed in each interview. The third reading was to organize, or clump, codes with similar meaning or topics into groups to identify themes. After a third reading, the primary investigator transferred the codes to notecards to organize support for each of the identified themes. Next, we diagrammed the themes by using color-coded representations of themes, subthemes, and codes for each interview (Figure 2; figure was modified from its original version to adhere to AORN Journal style). This process was completed for each interview, and after all interviews were conducted, we diagrammed themes for all to show crossinterview themes. The aggregation of codes to specific clusters allowed us to identify the themes for this study.5
RESULTS We found three main themes in this study: communication, clinical interaction, and clinician demeanor (Figure 3).
Communication The most prominent theme that surfaced in every interview was the importance of communication with the patient and the 196 j AORN Journal
They told us everything from the beginning to the end. What they were going to do, how they were going to do it, what to expect, the pros, cons, good, bad.
Communication with the OR clinical team often began before hospitalization. When both the nurse and the physician communicated with the patient before the procedure, patients and their family members reported less anxiety regarding the procedure. In the hospital, patients reported that they would like to see the surgeon before the procedure. Patients also mentioned that if they had seen or talked to the perioperative nurse before the surgical procedure, they felt more at ease.
Intraoperative communication During the surgical procedure, communication with the family was pivotal, especially regarding the length of the surgical procedure. Surgeons often provided an estimated time for completing the procedure, and as the estimated time of completion neared, family members reported growing more anxious. Most reported they would like to hear something about how the surgical procedure was progressing from a member of the OR team. If the estimated time passed with no report, family members reported greater anxiety and wished they could have heard from a member of the care team. One family member stated: The surgery [was] supposed to be done around 2:20 . . . if someone had physically come out and said, ‘everything is good, I know it’s going into a little further than what we first told you, so I just wanted to let you know that everything is good.’ [Participant did not complete statement]. Family members reported that they specifically liked hearing from the surgeon rather than other team members after the surgical procedure because they perceived the surgeon as the leader and “most in charge.” Family members reported that they liked to hear an estimated time after which they would be able to see the patient and a time at which the patient would return to the ICU. The specific topic of communication was also a subtheme that varied across individuals. Topics that were important included explaining what is happening (eg, why it is taking longer than expected, what steps are involved in the surgical procedure),
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Table 1. Semistructured Interview Questions When you think about the OR staff members communicating with the intensive care unit (ICU) staff members, what are the most important types of information that you want shared? Why is it important to you personally that the OR staff members communicate directly with the ICU staff members after your surgery? What are the most important things that you will tell the OR staff members, which you want communicated to the ICU staff members? Have you ever had surgery before? If YES: How could we improve the transfer of care so that you get better care? If NO: What types of information are you most worried about being communicated to the ICU staff members? Adapted with permission from the University of Texas Southwestern Medical Center, Dallas.
medications, patient condition, changes in condition, and what to expect in the short term. It became clear in the interviews that each patient and his or her family members had expectations of what they wanted the clinical team to discuss. Although consistent themes were demonstrated, participants tended to emphasize one particular priority over others. One family member discussed being part of a care plan meeting as an important way to understand clinical decision making: I heard how they weigh things out when there’s a team of doctors and I thought, wow, that would be nice to know. Why can’t I sit in on that . . . maybe they should have a premeeting and come to their conclusion and then have me come in? The family member reflected that it was important for her to hear the physicians “weigh things” by discussing the plan of action for her son’s care. Additionally, the premeeting she refers to may have involved shared decision making between her, her son (ie, the patient), and the clinical team before any care plan decisions were enacted. Table 2. Supplemental Follow-Up Questions Who would you like to communicate with? When would you like to communicate with each member of the team (eg, nurse, intensive care unit [ICU] physician, surgeon)? Have you observed any interactions or communication between the team members of the ICU and OR? Do you feel this communication was adequate? How were you prepared for the surgery? What expectations did you have for the surgery and transfers of care after your surgery? Adapted with permission from the University of Texas Southwestern Medical Center, Dallas.
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The last aspect of communication concerns frequency and quantity rather than quality. This aspect overlaps with the second theme, clinical interaction. The more the families observed the care teams communicating with each other, the more they were at ease. Therefore, if families are able to observe the OR team and the ICU team discussing the patient’s care, it may put the family at ease.
Clinical Interaction The second theme was clinical interaction, which was supported by two subthemes: nurse-to-nurse communication and visible team interaction. Clinical interaction refers to the specific discussions that occurred in and between the ICU and OR teams. Of note, neither physician-to-nurse nor physicianto-physician communication emerged as a specific subtheme. However, nurse-to-nurse communication was especially important for the family to witness during the transfer. For example, the patient in interview seven reported observing the nursing team discussing medication and physiologic changes (eg, blood pressure) during the transfer; this observation eased his concerns. The participant in interview four noted, “. . . [nurses] talked to each other. They were detailed.” She reported that this observation eased her postoperative anxiety. Communication about upcoming postoperative testing (eg, computed tomography scans) was important for family members to receive so that they knew what to expect and could make scheduling or visitation changes as needed. Another patient’s family member felt that both the OR and ICU team knew everything that happened to the patient, which led to the patient’s family member feeling safe. She stated, There’s a whole bunch of important information that isn’t communicated to us, but each other [clinicians]deverything that happened . . . they know what they’re looking for. AORN Journal j 197
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Figure 2. Supplemental digital material example of coding for a single interview. Adapted with permission from the University of Texas Southwestern Medical Center, Dallas.
The family members in this interview understood that they did not need to know all of the details of the medical care, but they wanted to know that the clinicians were knowledgeable about the patient when he or she was transferred from the OR to ICU. The second subtheme was visible team interaction. A better understanding of the responsibilities and roles of each team member better equipped family members to ask certain questions of each team member. As one patient explained, “Make sure everyone knows the chain of custody.” Another reported that he felt like a football team was around him during his transfer and this led to him feeling safe. A different patient’s family member recounted seeing the OR team in the ICU: “They all came . . . and they’re all business.” The family also agreed that seeing both teams during the transfer helped ease their worry, because they could see all members of the team communicating and caring for the patient. Increased visibility of the team may have lessened the family’s concern. 198 j AORN Journal
Clinician Demeanor The third theme was clinician demeanor toward the patient and family, which was supported by the subthemes of accountability and accessibility. For example, one individual commented, “We talked to the nurse that was in the operating room, and she told us how long she’d been doing this. She loves her job.” Interpretations of clinician demeanor were coded independently from clinical interactions, and the themes were supported by different codes. Interactions with other team members are observations of communication; demeanor is the outward behavior toward the patient and his or her family member. As one family member reported, “People were confident in their position.” The confidence this family member is referring to may be interpreted as the clinicians understanding their roles, being knowledgeable about patient details, and understanding the patient’s plan of care during the transition from the OR to the ICU.
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Figure 3. Inter-interview themes and subthemes. Adapted with permission from the University of Texas Southwestern Medical Center, Dallas. The patients and family members reported the effect of preoperative communication about what patients and families can expect. One patient reported, “He’s really good about letting people know the adventure they’re going to be on.” This comment referred specifically to the surgeon’s communication with her about the surgical procedures. The clinicians who provided open and honest communication about the procedure (eg, explaining expected and unexpected issues that occurred during the procedure and the postprocedure transfer) were perceived as more confident and decreased family and patient worry during the transfer from the OR to the ICU. The patients and families reported a desire for the following two items: access to the physician and accountability from the nurse. For participants, this meant they expected the nurse to follow through or follow up with them. Those patients and families who felt the physician was accessible (eg, preoperative phone calls, discussions with the surgeon immediately before the surgical procedure, talking to the surgeon immediately after the surgical procedure) were the patients and families who were most at ease. The patient in interview two mentioned the following exchange: The doctor called me personally . . . and said he looked it all over and said he wants “Dr Adam” to do the procedure. He made the phone call. I thought that was really good, you know, I heard from the doctor. The patient in interview seven also reported the importance of clinician accessibility: My wife and I have been highly impressed with [the surgeon’s] personableness and his demeanor and his willingness to take as much time as needed to answer questions and give us information about the situation. Accountability, the second subtheme, was directed toward nurses. The family wanted to be able to ask the ICU nurse
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about the patient and his or her care in the OR. Moreover, there was a sense that families wanted the nurse to be available, to know and understand the details about the patient (eg, blood pressure, heart rate, medications), and to know the answers to the families’ questions or know who to ask for the answers. For one family, accountability during a complication that occurred as the patient reached the ICU was especially important: They didn’t come out and tell us they were doing anything . . . maybe the doctor changed his mind after he talked to us . . . We waited for two or three hours, and there were complications. All we knew is we couldn’t go back there [to the ICU], and we all took turns asking if we could go back. This situation provides evidence of the critical and unstable state of a patient when being transferred from the OR to the ICU. The patient is the priority in these situations. An important team approach to lessen family stress of the unknown is to have a fellow team member report information to the family. In general, if the family members were able to receive answers regarding patient status, they reported experiencing less stress.
DISCUSSION The TOC can be a stressful time for patients, family members, and clinicians.2,3 Furthermore, the period before and after the TOC has been identified as a high-risk time for errors to occur. Researchers and clinicians agree that communication is essential and may improve patient outcomes, which is not surprising and supports literature on the importance of involving the patient and his or her family in decision making.4 The novelty of this study is its emphasis on how communication with patients and their families occurs during high-stress TOCs and the highlighting of the timing and topic of the information communicated.4
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Family members in our study believed communication should begin before hospitalization and continue through the surgical procedure to the postoperative period and be more inclusive. The topic of the conversation also was important. Some family members emphasized the importance of communicating physiologic changes; others simply wanted to know whom to speak with and how to get answers about the patient. One participant suggested a family team meeting before the procedure to meet the assigned clinical team members and to talk about specific concerns (ie, physiologic changes versus discharge information). Roter et al22 reported that nonverbal communication (eg, clinical demeanor) was as important as verbal. Nonverbal communication plays a large role in the way we understand others, and it has also been shown to affect patient outcomes.22 Clinicians who appeared to be empathetic, caring, available, and concerned were highly regarded. Patients and family members reported that these positive types of demeanor eased their anxiety. In general, research has shown that verbal and nonverbal communication with patients and families is important.23 Indicators of positive communication in specific hospital experiences (eg, TOC) are crucial to understand in the context of the patient’s, family members’, and clinicians’ experiences.
LIMITATIONS The nature of our study was qualitative, which presents a unique opportunity to understand a specific aspect of a problem. Qualitative research also lends itself to hypothesis generation for future research. Our study involved only seven interviews and thus is not indicative of the experiences or opinions of all surgical patients or the TOC process. Although there are strengths to qualitative methodology, the results may not be generalized to varying populations and locations. Our study used two interviewers, which made interviews more inconsistent, and some information may have been missed in certain interviews. The interviewers have varying backgrounds, and thus presented distinctly to the patients and families, which added to the richness of the data collected. We conducted the interviews during a stressful time, and therefore the responses of the patients and their families may have been skewed by the setting of the interview. This factor could also be seen as strength, because the researchers were able to capture unique data during this important time frame. 200 j AORN Journal
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CLINICAL PRACTICE RECOMMENDATIONS This study has several clinical implications. First, it supports the idea that communication with the patient and his or her family is important. Specifically, communication with the patient and family before and during the surgical procedure was endorsed in multiple interviews. We found that it was particularly helpful for both the patient and the family members to see the perioperative nurse and the surgeon before the procedure. The families reported wanting to communicate during the procedures, especially prolonged procedures and those in which duration exceeded initial time expectations. Immediately after the procedure, it was helpful for the family to communicate with the surgeon. The family also reported wanting to know specifically when and where they could see their family member. In the ICU, it was important for the patient and the family members to observe the OR and ICU RNs communicating about the specific status and physiologic changes of the patient. It was also important for the family members to be able to ask the ICU RN questions regularly after the TOC. The themes extracted from this study supported a sit-down meeting and a checklist (for the patient’s family to complete) as a pathway to the topics and type of desired communication with the clinical team. This checklist would allow patients and families to decide which staff member (eg, perioperative nurse, ICU nurse, surgeon, anesthesia professional, critical care physician) is most appropriate to communicate with the family, the timing of communication (ie, before, during, or after the surgical procedure and TOC), and the topics the family would like to discuss (eg, an overall discussion of the patient’s general well-being, specific physiologic factors). Clinicians may lack training on how demeanor affects patients’ families, but it is very important to patients and their families and should be something that is considered (eg, a calm, attentive demeanor promotes a calm patient or family). When possible during preoperative patient interviews, the clinical team can assist in preparing the surgeon with background about family dynamics, family wants and needs, and information that family members would like to have. The preparation could also be provided to the surgeon in a handout or checklist to prepare the surgeon to deliver desired information to the family.
CONCLUSION Our study has implications for all clinical team members caring for critically ill patients. The TOC from the OR to the
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ICU occurs in the last few moments before the family and patient are reunited after the surgical procedure; therefore, this time is full of anxiety for the family and patient. Easing tension and anxiety is an important part of clinical care. Structured time and handouts may be one manner in which the TOC can be standardized to meet the needs of the patient, family members, and clinical teams in an efficient manner. Future studies are needed to test these potential avenues of communication during the TOC. Themes may include whom the patient wishes to speak with, timing of communication, and topics. Interventions should be developed and prospectively tested to address each of the communication themes and subthemes.
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cardiac surgery patients to the intensive care unit. Pediatr Crit Care Med. 2011;12(3):304-308. Merriam SB. Qualitative Research in Practice: Examples for Discussion and Analysis. San Francisco, CA: Jossey-Bass, Inc; 2002. Merriam SB, Tisdell EJ. Qualitative Research: A Guide to Design and Implementation. Hoboken, NJ: John Wiley & Sons; 2015. Catchpole KR, De Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth. 2007;17(5):470-478. Beckmann U, Gillies DM, Berenholtz SM, Wu AW, Pronovost P. Incidents relating to the intra-hospital transfer of critically ill patients. Intensive Care Med. 2004;30(8):1579-1585. Flick U. An Introduction to Qualitative Research. 5th ed. Thousand Oaks, CA: SAGE Publications; 2014. Higgs J, Paterson M, Kinsella EA. Hermeneutic inquiry: interpretation and understanding in research practice. Contemporary Psychotherapy. http://www.contemporarypsychotherapy.org/vol-4 -no-1-spring-2012/hermeneutic-inquiry. Accessed October 12, 2016. Luborsky MR, Rubinstein RL. Sampling in qualitative research: rationale, issues, and methods. Res Aging. 1995;17(1):89-113. Creswell JW. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. 2nd ed. Thousand Oaks, CA: SAGE Publications; 2007. Trochim WM. Research Methods: The Concise Knowledge Base. Mason, OH: Atomic Dog Publishing; 2005. Roter DL, Frankel RM, Hall JA, Sluyter D. The expression of emotion through nonverbal behavior in medical visits: mechanisms and outcomes. J Gen Internal Med. 2006;21(suppl 1):S28-S34. Manary MP, Boulding W, Staelin R, Glickman SW. The patient experience and health outcomes. New Engl J Med. 2013;368(3): 201-203.
Sonja E. Stutzman, PhD, is a clinical research coordinator in the Department of Neurology and Neurotherapeutics at the University of Texas Southwestern Medical Center, Dallas. Dr Stutzman has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
DaiWai M. Olson, PhD, RN, CCRN, FNCS, is an associate professor in the Department of Neurology and Neurotherapeutics and the Department of Neurosurgery at the University of Texas Southwestern Medical Center, Dallas. As the editor-in-chief for the Journal of Neuroscience Nursing, Dr Olson has declared an affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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Philip E. Greilich, MD, is a professor in the Department of Anesthesiology and Pain Management at the University of Texas Southwestern Medical Center, Dallas. As the recipient of a grant from the University Hospital, San Antonio, TX, Dr Greilich has declared an affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Kamal Abdulkadir, BSN, RN, is a bedside nurse in the neurointensive care unit at Zale Lipshy University Hospital in the University of Texas Southwestern Medical Center, Dallas. As the recipient of a grant from
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Michael A. Rubin, MD, MA, is an assistant professor in the Department of Neurology and Neurotherapeutics and Department of Neurosurgery at the University of Texas Southwestern Medical Center, Dallas. Dr Rubin has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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