Intensive Care Unit Follow-Up Participatory Design of the ICU Follow-Up when Patients Transfer from the ICU to a General Ward

This PhD dissertation explores the collaboration between nurses working in the intensive care unit (ICU) and general wards. The focus is on the follow-up plan initiated by the ICU nurse intended for use in the initial 24 hours after patient transfer.

Problem: In 2008, the studied ICU implemented ICU follow-up after a patient was transferred to a general ward, but they had not evaluated the implementation. The ICU perceived that the general wards did not receive the follow-up plans well and that this had a negative effect on the care, leading to the readmitting of the patients to the ICU as a consequence. This came to the great frustration of the ICU nurses because they did not understand why the general ward nurses did not comply with the detailed plan. This led to the following research question:

How can we establish an understanding between nurses in an ICU follow-up, and what does the establishment of relationships mean to the coordination in the follow-up?

Method: Throughout the research period, a participatory design approach was used to gain insights into the patient transfer from the ICU to a general ward, the receiving of the patient and the follow-up plan. During the process of revealing the challenges, both the ICU and three general wards were invited. The ICU and general wards did not share documentation systems regarding nursing. This is why the Imatis electronic whiteboards (henceforward e-whiteboards) were chosen for the new ICU follow-up plan. The e-whiteboards showed, for example, upcoming exams and new results for each patient at the given ward. The e-whiteboards were mounted in shared office spaces in each ward, and all staff members could interact with the available information. During the initial participatory design workshops, 85 nurses participated and identified challenges in the ICU follow-up. The participants also designed the first paper mock-ups of the new ICU follow-up plan and process of patient handover and follow-up visits. Next, two design workshops were conducted, and four wards
participated. Finally, two evaluation work- shops were conducted.

Results: The Handover from Intensive Care Unit to General Ward (K. L. Østergaard et al., 2019) reveals the need for a new approach to ICU follow-ups of patients when they are transferred from the ICU to a general ward. The study also reveals that the lack of follow-up can have fatal consequences for patients. Examining Situated Design Practices (K. L. Østergaard et al., 2018) describes the participating nurses’ design process. The learning processes during the design process established a new understanding of each other’s work and expertise. The understanding of one’s own and others’ values in the work with the patient created an explicit recognition and respect for one another and for each person’s different work practices. With this new understanding of one’s own and others’ work, it became clear that the first design draft of the ICU follow-up plan would not work in its checklist format with boxes to tick off for each item when completed and at preset points in time. A New Model for ICU follow-up (K. Østergaard, 2022) describes the nurses’ second design product of the ICU follow-up plan. This paper describes the differences between the new model for ICU follow-up and traditional checklist format. The paper describes how to use the new model in clinical practice. The nurses’ new model was designed from the perspective that ICU nurses have one kind of expertise and work routine, while nurses from the general wards have another. Both are experts within their own fields, which is why the new model for ICU follow-up made room for the nurses from the general ward to draw on their expertise regarding the execution of the follow-up plan and to do so according to their own work routines. In return, the new model also required that the nurses take responsibility for the patient and nursing items in the follow-up plan.

Unfortunately, the nurses’ new model for ICU follow-up was not implemented in the e-whiteboards because of political and organisational decisions. Nothing could be done from our side. Because of these decisions, it was impossible to evaluate the full-scale implementation of the new model. The model was tested in paper version and on a far smaller scale. The preliminary evaluation is elaborated on in chapter 9, which here emphasises the importance of involving users and the potential of participatory design (PD) in Danish healthcare. The nurses highlighted that this was the first time they were asked about procedures that had a direct influence on their clinical practice. This made them feel a special kind of ownership of the new model for ICU follow-up. They were frustrated that their designs were prevented from being implemented.

Conclusion: The overall conclusion is that for nurses to establish an understanding of one another’s work in the patient transfer from the ICU to a general ward, they must meet face to face and build a shared understanding. Through shared understanding, the nurses can coordinate the patient handover and ICU follow-up with respect to one another’s expertise and work practices and with shared goals for the patient.

PD has been an important approach in reaching this understanding. The approach has also led to strengthened innovation and collaboration between the nurses at the ICU and general wards. The strengthened innovation was exemplified in the design product, which reflected respect and understanding of expertise and work practices. The design product was a result of the PD processes and accomplishing a relational understanding, which made the participants reposition themselves from the traditional approach to patient transfers, patient handovers and ICU follow-up. The nurses participating in designing the ICU follow-up contributed with an important input to the research within ICU follow-up, collaboration across wards and their perspectives on being nurses and specific expertise.