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Intensive and Critical Care Nursing (2007) 23, 362—369

ORIGINAL ARTICLE

The effect of an ICU liaison nurse on patients and


family’s anxiety prior to transfer to the ward:
An intervention study夽
Wendy Chaboyer a,∗, Lukman Thalib b, Kristie Alcorn c, Michelle Foster d

a Research Centre for Clinical Practice Innovation, Griffith University, PMB 50 Gold Coast Mail Centre,
Bundall, Qld 9726, Australia
b Faculty of Medicine, Kuwait University, Adjunct Professor Research Centre for Clinical Practice

Innovation, Griffith University, Australia


c School of Psychology, Griffith University, Australia
d Nurse Unit Manager ICU, Gold Coast Hospital, Australia

Accepted 14 April 2007

KEYWORDS Summary While an admission to the Intensive Care Unit (ICU) is stressful, the
Transfer anxiety; impending transfer from ICU to the ward can also result in anxiety for patients and
ICU nursing their families. The aim of this study was to identify the effect of an ICU liaison nurse
interventions; on anxiety experienced by patients and their families just prior to transfer to the
Family centred care ward. This block intervention study used a repeated before and after design, with
the first control and intervention periods of 4 months, a wash-out period of 1 month,
and then a second control and intervention period of 4 months duration. That is,
after 4 months of control and another 4 months of intervention, the liaison nurse
services were withdrawn and no data collection occurred for a month (wash-out)
then a second set of 4-month blocks of control and intervention were undertaken. A
standard transfer protocol was followed during the control periods whereas during
the intervention periods, the liaison nurse prepared patients and their families for
transfer to the ward. The State Trait Anxiety Form Y (State) was used to measure
anxiety just prior to physical relocation to the ward. A total of 115 patients (62 con-
trol, 53 intervention) and 100 families (52 control, 48 intervention) were enrolled in
the study. There was no difference in anxiety scores between the control and inter-
vention groups in either patients or family groups. This study did not demonstrate a
statistically significant beneficial effect of the liaison nurse in terms of pre-transfer
anxiety, however it highlights several methodological issues that must be consid-
ered for future research including sample size estimates, timing and measurement
of transfer anxiety and finally the intervention itself.
© 2007 Elsevier Ltd. All rights reserved.

夽 This study was conducted at Griffith University and the Gold Coast Hospital.
∗ Corresponding author. Tel.: +61 755 528 518; fax: +61 755 528 526.
E-mail address: W.Chaboyer@griffith.edu.au (W. Chaboyer).
0964-3397/$ — see front matter © 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.iccn.2007.04.005
The effect of an ICU liaison nurse on pre-transfer anxiety 363

The Intensive Care Unit (ICU) can be a stressful from the information, contact and guidance pro-
experience, not only for patients, but also for their vided by ICU staff (Chaboyer et al., 2005a; Hupcey,
families (Chaboyer et al., 2005a; Frazier et al., 1999; Mitchell et al., 2003). In contrast, transfer
2002; McKinley et al., 2003). Anxiety is an emotion from the ICU to the general ward can be extremely
and is a subjective, uniquely individual experience anxiety provoking for family members leading to
(Sadock and Sadock, 2003). It has been defined by intense anxiety at the time of discharge (Mitchell
the North American Nursing Diagnosis Association et al., 2003).
(NANDA) as ‘‘A vague, uneasy feeling of discomfort Research demonstrates that several environmen-
or dread accompanied by an autonomic response, tal and personal factors contribute to transfer
with the source often non-specific or unknown to anxiety (McKinney and Melby, 2002). For example,
the individual; a feeling of apprehension caused by transfer anxiety has been associated with envi-
anticipation of danger’’ (Schweitzer and Ladwig, ronmental factors, such as sudden transfer due
2002, p. 144). Anxiety is estimated to occur in up to the need for an ICU bed (Cutler and Garner,
to three-quarters of critical care patients (Frazier 1995; Leith, 1999); lack of constant nurse presence
et al., 2002) and signals that a threat of some (Chaboyer et al., 2005a; Leith, 1999); lack of moni-
type has stimulated the stress response (Frazier toring equipment (Cutler and Garner, 1995); change
et al., 2002). In ICU patients, the origin of anx- in the environment (Chaboyer et al., 2005a; Cutler
iety may be both physiological and psychological and Garner, 1995; McKinney and Melby, 2002); and
given the alien critical care environment. Excessive the lack of predictability in the new environment
and foreign noise, disturbed sleep, the presence (Chaboyer et al., 2005a; Cutler and Garner, 1995).
of sophisticated and unfamiliar technology, loss Other factors found to contribute to transfer anxi-
of privacy, inability to communicate effectively, ety have included lack of information (Burr, 1998;
restricted mobility, and fear of death or disability Chaboyer et al., 2005a, 2005b; Cutler and Garner,
are common to the critical care experience (Frazier 1995; Hall-Smith et al., 1997; Leith, 1999); lack
et al., 2002). of preparation (Chaboyer et al., 2005a; Cutler and
Although discharge from ICU is a positive step in Garner, 1995); and concerns regarding lack of inten-
terms of physical recovery, many patients exhibit sive nursing care (Chaboyer et al., 2005a; Leith,
high levels of anxiety at the time of relocation from 1999; McKinney and Melby, 2002).
the ICU to a general ward (Barbetti and Choate, To complicate this anxiety, transfer to the ward
2003; Chaboyer et al., 2005a; Cutler and Garner, sometimes occurs so quickly that patients and their
1995; Leith, 1998; McKinney and Melby, 2002). Over families receive little preparation about what to
30 years ago, the term transfer anxiety was used to expect in terms of nursing care, unit routine, ori-
describe the ‘‘anxiety experienced by the individ- entation to the nurse call system, or bathroom
ual when he/she moves from a familiar, somewhat facilities (Chaboyer, 2006; Cutler and Garner, 1995;
secure environment to an environment that is unfa- Leith, 1999; Maillet et al., 1993). After one-on-one
miliar’’ (Roberts, 1976, p. 227—8) and today it nursing care in the ICU, patients and their fami-
is an accepted North American Nursing Diagnosis lies may feel rejected and abandoned at discharge
(Schweitzer and Ladwig, 2002). This definition is (Chaboyer et al., 2005a; McKinney and Melby,
consistent with anxiety that has been termed state 2002). They are frequently so anxious about being
anxiety rather than trait anxiety. State anxiety is left alone that they display dependency behaviour
described as how an individual feels ‘‘right now,’’ (McKinney and Melby, 2002). Similarly, a heightened
at this present moment, rather than underlying level of anxiety in family members is associated
‘‘trait’’ anxiety, a relatively stable personality trait with repeated questioning of staff (Mitchell et
over time. al., 2003). Ironically, while these behaviours may
Transfer anxiety is a transcultural phenomenon temporarily reduce their anxiety, it constrains the
that can occur in all age groups and may also affect opportunity for the establishment of a therapeu-
the person’s family members and significant oth- tic relationships with nursing staff. Dependency
ers (Chaboyer, 2006; Gustad et al., 2005; Leith, behaviour can be ‘‘terribly burdensome’’ on nurses
1999). More specifically, families have been found (Standberg, 2003) and can impact negatively on the
to experience anxiety prior to, during and after development of positive therapeutic relationships
the transfer from the ICU (Chaboyer et al., 2004; (Hupcey, 1998).
Leith, 1999). Although ICU admission of a relative is Given the potential impact of transfer on the
extremely stressful, the sense of security provided physical and psychological wellbeing of patients
by ICU care is likely to be reassuring for families and their families, developing interventions to
(Hupcey, 1999; McKinney and Melby, 2002; Mitchell reduce anxiety is an important task. In some
et al., 2003). Families gain comfort and support patient groups, such as those undergoing cardiac
364 W. Chaboyer et al.

catheterisation (Mott, 1999), spinal fusion surgery The Human Ethics Committees of the univeristy and
(LaMontagne et al., 2003) and oral surgery (Ng hospital approved this study. Informed consent was
et al., 2004), psychological preparation has been obtained from both patients and next of kin.
shown to reduce anxiety. These, and other find- A computerised database was used to access
ings in the area of anxiety reduction, have led patients’ demographic and clinical information
researchers to question how nurses can reduce the such as gender, age, diagnosis and ICU length of
anxiety of patients during the transition from ICU stay. Pre-transfer anxiety was measured just prior
to the ward. Recently, in Australia the liaison nurse to the patient transfer to the ward using the
role has been proposed to assist the patient and State-Trait Anxiety Inventory (STAI) Form Y-1 (State
families in their transition to the ward (Chaboyer Anxiety) (Spielberger et al., 1983). The STAI is a
et al., 2004, 2006; Green and Edmonds, 2004). The self-report instrument that measures symptoms of
liaison nurse typically provides education and sup- anxiety rather than diagnosing specific anxiety dis-
port to patients and their families prior to and after orders. The STAI Form Y-1 contains 20 items that
transfer in order to prepare them for the move and measures ‘‘state’’ anxiety (how an individual feels
adjustment to the ward environment (Chaboyer et ‘‘right now’’). Respondents rate their level of anxi-
al., 2004). This paper reports on the impact of an ety using a four-point scale, which ranges from ‘‘not
ICU liaison nurse on anxiety experienced by both at all’’ to ‘‘very much.’’ Possible responses for each
patients and their families just prior to transfer in item are from 1 to 4 with possible total score rang-
one Australian hospital. ing from 20 to 80. A comprehensive review of 52
studies that used the State scale identified that
the mean internal consistency was 0.91 (±0.05)
(Barnes et al., 2002). The validity of the STAI has
Method been demonstrated in using the contrasted group
approach using students and military recruits (see
The research hypothesis was: the liaison nurse ser- Spielberger et al., 1999 for a full description).
vices will decrease the anxiety patients and families Both patients and families completed the STAI upon
experience just prior to transfer to the ward. pending transfer of the patient from the ICU to the
A block intervention study was conducted in an ward and at the point of physical preparation for
Australian tertiary adult combined medical and sur- the transfer.
gical ICU, which has approximately 1000 admissions
per year. A randomised control trial was not possible Liaison nurse intervention
because there was no way to prevent contamina-
tion between the groups. Thus, this was the next The role of the ICU liaison nurse is an example
best design to demonstrate the effect of the liai- of a ‘‘bundled intervention’’ (Conn et al., 2001),
son nurse. The study site did not have a dedicated meaning that the liaison nurse undertook a num-
High Dependency or Step Down Unit or Medical ber of activities, that together were considered as
Emergency Team at the time of the study. Transfer a treatment package. Treatment packages are then
was from the ICU to the wards. Four blocks were tailored to individual patients, depending on need.
conducted, with each block lasting for 4 months The advanced nursing practice framework informed
duration. The first two blocks consisted of a con- this treatment package (International Council of
trol and intervention period, which were followed Nurses, 2005). It was developed from a review of
by a 1-month wash-out period. The wash-out period the literature (Chaboyer et al., 2005a,b) and from
was used to allow for any residual effects of the focus groups with ICU survivors (Chaboyer et al.,
liaison nurse intervention to dissipate. The control 2005a), their families (Chaboyer et al., 2005a), ICU
and intervention blocks were then repeated. All and ward nurses and a short survey of ICU nurses
patients who could speak and write English were perceptions of discharge planning (Chaboyer et al.,
invited to participate in the study if their length of 2002). As a result of the information gathered from
ICU stay was greater than 3 days and if they were the review and the other data sources, a position
able to provide consent. The time limit of 3 days description for the liaison nurse was developed. It
was included to ensure that the ICU experience was documented that the nurse provided assessment of
of sufficient duration for patients to experience the patients for transfer to the ward, focusing primar-
technical environment and develop a relationship ily on the coordination of ICU patient transfer and
with the ICU nurses, both of which are thought to liaison with ward staff. Tasks included communicat-
form the basis of transfer anxiety (Roberts, 1976). ing with ward staff, assessing ward staff skill-mix
Patients and families were enrolled once, on their and resources, preparing both the ICU and ward
first admission to the ICU during the study period. staff for patient transfer, and assessing bed status.
The effect of an ICU liaison nurse on pre-transfer anxiety 365

Other aspects of the role included the provision of to compare the median scores of the patients and
clinical support and resources to ward nurses, as families’ STAI scores between the intervention and
well as providing education and advice to increase the control. Further analyses were carried out after
their capacity to receive and manage ICU patients. classifying the patients and the families into having
Importantly, the liaison nurse provided practical high and low anxiety. Anyone who had a total score
and emotional support and education to patients of less than 40 was classified as having low anxiety
and their families before and after discharge. Thus, and those with the score of 40 or more were classi-
one aim of the role was to diminish pre-transfer fied as having a higher level of anxiety. The cut off
anxiety, something nurses in the study site were was determined by the approximate median split
focused on. method. Crude and adjusted odds ratios and 95%
The liaison nurse services were available 8 h per confidence intervals were calculated for patient
day, Monday to Friday (day shift) and up to 4 h per and family anxiety scores separately using multi-
day on the weekend. Weekend service was limited ple logistic regression. A number of variables that
because fewer discharges occurred on the week- were thought to have a potential effect on the
ends. The service was provided by one full-time and association between the liaison nurse interven-
one-part time nurse, dedicated to the role. They tion and anxiety were entered into the statistical
followed a set of guidelines and used a comprehen- model in order to adjust the odds ratios for these
sive ICU booklet in their education, however patient factors.
or family contact was individualised. Patients were
seen at the bedside, whereas families were gen-
erally seen away from the bedside, when a formal
ICU booklet was reviewed, which included what to Results
expect on the ward. Because preparing patients and
families generally occurred for a day or two prior to During the study period a total of 1092 patients
actual transfer, even patients transferred at night were discharged alive from the ICU. From this
received the service. While most patients and fam- group, 115 patients (53 intervention and 62 control)
ilies received one to two pre-transfer visits by the stayed 3 or more days in the ICU and were able to
liaison nurse, some received more, which reflects give informed consent. Fig. 1 demonstrates the tar-
the theoretical notion of a ‘‘treatment package’’ get population and final sample. Not all next-of-kin
(Conn et al., 2001). Thus, testing the effect of the were present during the transfer period, however,
liaison nurse intervention in this study reflected all that were present agreed to participate. From
what was most likely to occur in practice, increas- the 115 patients, 100 families (48 intervention and
ing its external validity. 52 control) participated in the study and completed
the family STAI. The Cronbach’s alpha reliabilities
Data analysis for the patient and family STAI scores were 0.59 and
0.62, much lower than expected based on previous
Total STAI scores for both patients and families research.
were computed using the responses to 20 questions Table 1 provides demographic and clinical char-
and Cronbach’s alpha reliability calculated. Ini- acteristics of the patients. Although there were no
tial comparisons using participants’ STAI responses statistical differences between the two groups, the
were conducted between the two blocks of con- trends of the control group experiencing longer ICU
trol and two blocks of intervention. Because there length of stay, ICU readmissions and hospital death
were no differences within the blocks, data were approached significance.
combined and further analyses were undertaken There were no statistical differences between
between the pooled control and pooled interven- pre-transfer anxiety scores for patients and fam-
tion groups. Associations between intervention and ily members in the control and intervention groups
demographic, clinical and ICU and hospital related (see Table 2). While not significant, a trend of
variables were initially tested using appropriate slightly lower median scores was evident for the
non-parametric statistical methods. The chi-square intervention group, particularly for the patients.
test was used to compare the variation in the Table 3 provides the odds ratio for patient and
categorical variables between intervention and family anxiety scores. Although the point estimates
control. Mann—Whitney test was used to compare indicates a potential benefit of the liaison nurse
the median anxiety scores between the interven- (see un-adjusted odds ratio), they were not signif-
tion and control groups for those scale and score icant. This was the case even after adjusting for
variables due to fact that the variables were skewed factors such as age, gender, emergency or operative
to the left. Mann—Whitney tests were also used admission, and ICU and hospital length of stay.
366 W. Chaboyer et al.

Figure 1 Target population and final sample.

Table 1 Demographic and clinical characteristics of the patients (n = 115)


Controla (n = 62), Interventiona (n = 53), P-valueb
median (IQR) median (IQR)
Age 59 (21) 57 (26) 0.52
Hospital length of stay in days 15.5 (16) 18 (17) 0.57
ICU length of stay in hours 117 (71) 146 (122) 0.09
SAP Score 19 (12) 19 (13) 0.87
APACHE II Score 17 (10) 15 (9) 0.26

Controla (n = 62), n (%) Interventiona (n = 53), n (%) P-valueb


Male 36 (58.1) 31 (58.5) 0.96
Emergency admission 54 (87.1) 47 (88.7) 0.80
Operative admission 20 (32.3) 18 (34.0) 0.85
ICU readmissionc 4 (6.6) 0 (0.0) 0.06
Chest tube or tracheostomy 3 (4.8) 7 (13.2) 0.11
in situ on ICU discharge
Hospital death 4 (6.5) 0 (0.0) 0.06
a Values given are frequency (percentage) for the categorical variables and median (IQR) for other variables.
b Based on chi-square test for categorical variables and Mann—Whitney U-test for all other variables.
c Represents readmission during the same hospital admission.

Table 2 Comparison of state anxiety scores between the intervention and control groups
Control, median (IQR) Intervention, median (IQR) P-valuea
Patient STAI 40 (21.6) (n = 62) 37 (18.5) (n = 53) 0.28
Family STAI 40.7 (26.8) (n = 52) 39 (16.7) (n = 48) 0.72
a Mann—Whitney U-statistics.
The effect of an ICU liaison nurse on pre-transfer anxiety 367

Table 3 Crude and adjusted odds ratio and 95% confidence interval for patient and family anxiety levels (score
≥40 or <40) between control and intervention groups
Odds ratio (95% confidence interval)
Patients anxiety (n = 115) Family anxiety (n = 100)
Un-adjusted (i.e. only the LN intervention) 0.77 (0.37—1.60) 0.85 (0.39—1.87)
Age adjusted 0.78 (0.37—1.64) 0.86 (0.39—1.89)
Age and gender adjusted 0.78 (0.37—1.64) 0.86 (0.39—1.89)
Age, gender and emergency admission adjusted 0.78 (0.37—1.64) 0.86 (0.39—1.90)
Age, gender and operative admission adjusted 0.78 (0.37—1.64) 0.86 (0.39—1.88)
Age, gender and use of any device adjusted 0.73 (0.34—1.56) 0.86 (0.38—1.90)
Age, gender and hospital length of stay adjusted 0.78 (0.37—1.64) 0.86 (0.38—1.91)
Age, gender and ICU length of stay adjusted 0.80 (0.38—1.69) 0.87 (0.39—1.93)
Age, gender, ICU and hospital length of stay adjusted 0.80 (0.38—1.70) 0.87 (0.39—1.96)

Discussion The conclusion could be reached that the addi-


tional information provided by the liaison nurse
A total of 115 patients and 100 family members did not affect the level of anxiety experienced
participated in this study. All eligible patients and by patients or family members. This is unlikely,
all families available during the transfer process however, as the research results indicated that
agreed to participate. This study found that the the anxiety levels of the intervention group were
ICU liaison nurse did not have a significant effect comparable to norms found in the ‘‘general’’ pop-
on quantitative measures of patient or family pre- ulation, whereas the anxiety levels of the control
transfer anxiety despite controlling for a number of group were comparable to those found in the gen-
demographic and clinical variables. This finding was eral medical patient population (Spielberger et al.,
surprising, as it does not reflect the commonly held 1983). Therefore, it is possible that the interven-
belief that the provision of information and support tion had a positive influence on patient anxiety
will diminish the stress and anxiety experienced by levels and it may be that with a larger sample
patients and their families (Chaboyer et al., 2004; size, this difference could reach statistical signif-
McKinley et al., 2003). However, little empirical icance.
evidence actually exists about the impact of such Detection, explanation and treatment of inten-
a role on psychosocial outcomes. Leith (1999) sug- sive care related complications have the potential
gested that nurses could identify individuals who to contribute significantly to patients’ rehabilita-
are at high risk of transfer anxiety simply by asking tion (Sawdon et al., 1995). In order to decrease
the patient and their family how they felt about the patient and family anxiety, nurses must be able
transfer from the ICU. Yet, the ability to address to identify and respond to the signs and symp-
anxiety during an ICU transfer is not well under- toms of anxiety. However, Curry (1995) identified
stood. that 9 out of 10 nurses did not feel adequately
Some researchers have identified a number of prepared to cope with stressful situations involv-
activities that ICU nurses can undertake to diminish ing the relatives of patients. Although the liaison
transfer anxiety. These activities include encourag- nurse in this study had over 20 years of ICU experi-
ing patient autonomy before transfer (Cutler and ence, she was not trained in counselling. Wilkinson
Garner, 1995; Leith, 1999); early notification of (1995) identified that counselling skills were ben-
the potential for transfer to the ward (Cutler and eficial if a liaison between patients and families
Garner, 1995); visits by ward nurses to patients in was to take place. It is not known whether these
the ICU (Cutler and Garner, 1995); systematically skills would have benefited ICU patients or their
assessing personality profiles of families (Quinn et families.
al., 1996; Wilkinson, 1995); and assessing rela- There are several limitations of this study. First,
tives’ needs and providing information as required anxiety was measured only once, just after being
(Quinn et al., 1996; Wilkinson, 1995). Many of notified of planned transfer. Obtaining several mea-
these activities formed the basis of the role for sures of anxiety both before and after transfer may
the ICU liaison nurse. However, these activities did provide a better understanding of anxiety expe-
not significantly reduce pre-transfer anxiety in this rienced during this time period and may provide
sample. insight into when an intervention aimed at reduc-
368 W. Chaboyer et al.

ing anxiety would be most beneficial. Second, the Acknowledgements


internal consistency reliability was much lower than
expected and lower than many previous studies, Financial support for this study was received
a very unexpected finding given it widespread use from the Australian Research Council, the Gold
in numerous clinical populations. This finding sug- Coast Hospital Foundation and the Gold Coast ICU
gests that the STAI Form Y (State Anxiety), was Research Trust fund.
not appropriate for the ICU population. It may be
too long an instrument for ICU patients and their
families to complete. Since the time of this study,
the Hospital Depression and Anxiety Scale (Zigmund References
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