Perceptions of transitional care services among patients with percutaneous transhepatic biliary drainage and multicentre health professionals: A qualitative study

Abstract Background Patients with percutaneous transhepatic biliary drainage (PTBD) need regular drainage tube care after discharge, and transitional care can help solve this problem. However, few studies have focused on the quality of transitional care, the perceptions of patients with drainage tubes after discharge and those of healthcare professionals. Aim This study is aimed at exploring the real experience and perceptions of transitional care services among healthcare professionals and PTBD patients who have been discharged with tubes and at providing references for future transitional care service development. Design The study uses a qualitative descriptive design. The reporting method followed Consolidated Criteria for Reporting Qualitative Research guidelines. Methods Semistructured interviews were conducted with PTBD patients who had been discharged with tubes and multicentre healthcare professionals using the purpose sampling method. The thematic analysis method was used for analysis. Results Thirteen PTBD patients from one hospital and 12 healthcare professionals from three hospitals were interviewed. The analysis of the patient interview data revealed three themes, namely, recognition of the value of transitional care services, patients have some unmet needs and perception of transitional care service pathways. Six subthemes were also identified. The analysis of the interview data of healthcare professionals revealed two themes, namely, harvest and challenges in transitional care services work and expectations for future development of transitional care services. Four subthemes were also identified. Conclusions The transitional care of discharged patients with PTBD tubes deserves the attention of clinical workers, and a series of measures should be taken to improve transitional care services. Patient/Public Contribution Patients were involved in the formulation of interview questions for this study, and during the interviews, patients presented their suggestions for transitional care services. Healthcare professionals participated in this study as interviewees, and no members of the public were involved in this study.

Patient/Public Contribution: Patients were involved in the formulation of interview questions for this study, and during the interviews, patients presented their suggestions for transitional care services.Healthcare professionals participated in this study as interviewees, and no members of the public were involved in this study.
percutaneous transhepatic biliary drainage, qualitative study, transitional care

| INTRODUCTION
Obstructive jaundice is a clinical symptom caused by benign and malignant lesions that occur in or near the biliary tract, such as gallstones, pancreatic head cancer and gallbladder cancer, which prevent bile from flowing into the duodenum and lead to increased levels of bilirubin in the blood.Obstructive jaundice is characterized by abnormal yellow skin, mucosa and sclera, itching and dark urine. 1,2 recent years, the incidence of these diseases has been increasing.For example, in 2020 alone, there were nearly 1.51 million new cases of pancreatic, liver and gallbladder cancer worldwide, reflecting an increasing prevalence of obstructive jaundice. 3Most patients with malignant obstructive jaundice are in the middle and late stages of the illness when they are diagnosed, making it difficult to carry out surgical treatment, so palliative treatment is the only choice at that time. 4rcutaneous transhepatic biliary drainage (PTBD) has been widely used in the clinical treatment of obstructive jaundice due to its advantages of simplistic operation, a high success rate and the rapid relief of symptoms. 5,6Patients are generally discharged with tubes after their condition stabilizes to reduce costs and improve hospital efficiency. 7Patients with benign obstruction should have their tubes indwelled for at least 12 days. 8Patients with malignant obstructive jaundice need to wear the tube until the end of their lives. 4Some studies have found that PTBD patients with catheters are prone to complications such as catheter displacement, bleeding and bile leakage after surgery, and the rate of unplanned readmission within 30 days due to drainage tube dysfunction is as high as 63.9%. 9,10erefore, nursing continuity should be strengthened to improve the quality of life of PTBD patients after discharge.
Transitional care has been defined as 'a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or levels of care within the same location', 11 including hospital discharge planning, referrals, ongoing follow-up and the provision of guidance when patients return home or to their community. 12Transitional care can be effective in helping patients transition to home or other care settings, and its proper implementation accounts for factors such as the situation of the patient and his or her family, the members of the healthcare team and the relevant environmental and social conditions. 13Understanding the patient experience and actual needs is the basis of transitional care and the premise of implementing patient-centred care. 14derstanding the views of healthcare providers can help further the implementation of transitional care.However, the majority of the current studies on transitional care for PTBD patients are intervention studies exploring the effects of different transitional care modalities.A very small number of studies have focused on the quality of transitional care services for PTBD patients and explored the experiences and perceptions of PTBD patients and healthcare professionals regarding the current transitional care services through a qualitative study. 15Therefore, by interviewing both discharged PTBD patients and healthcare professionals, this study aimed to explore their perceptions regarding the current transitional care services to provide references for establishing better transitional care for PTBD patients to improve their quality of life.

| Design
A descriptive qualitative research design is adopted for this study. 16is methodology is appropriate for identifying and understanding a phenomenon, a process or the perspectives of participants.Moreover, this study used the Consolidated Criteria for Reporting Qualitative Research 17 (COREQ) as a guide in the reporting phase to explicitly and comprehensively report the study results (see Appendix S1).

| Selection of participants
From January to March 2023, a purposive sampling method, which includes criterion sampling and maximum variation sampling, was used in this study to select participants from among PTBD patients and healthcare professionals in the Department of Hepatobiliary Surgery of a 3500-bed university teaching hospital in Chongqing, China.In addition, to provide a more thorough grasp of the opinions of healthcare professionals, members of the nursing staff from other hospitals in Chongqing were also enlisted as participants in this study, which was conducted from a multicentre perspective.
The inclusion criteria for patients with PTBD tubes were as follows: (1) patients were ≥18 years; (2) patients spent 1 month or longer with a PTBD tube and had received transitional care services before returning to the hospital for the subsequent phase of therapy or drain care; (3) patients exhibited sufficient cognitive and communication ability to provide informed consent and participate in the interviews.The exclusion criteria consisted of the presence of severe disease or complications in patients.
The inclusion criteria for healthcare professionals were as follows: (1) doctors and nurses had to have been engaged in medical or nursing work with a specialization in hepatobiliary surgery in tertiary hospitals for 5 years or more; (2) these medical professionals must have experience conducting transitional care services for PTBD patients, specific elements of transitional care services including establishing a transitional care team (doctors, nurses, etc.), collaborating with team; assessing patients and families' situation to create plans for transitional care; patients and families health education at the time of discharge (including how to take care of drains and skin, how to take medication, when to schedule follow-up appointments, etc.); maintaining relationships with patients, following up with regular phone calls after the patient is discharged from the hospital; and using the internet and other resources to answer questions and offer guidance to patients, promoting care continuity; (3) healthcare professionals must have a bachelor's degree or above.Exclusion criteria consisted of medical personnel who were currently undergoing training.The sample size calculation followed the principle of data saturation, which means that recruitment ceased when no new information was obtained through interviewing additional participants. 18

| Recruitment procedure
The study team travelled to the ward and explained the purpose of the interview to those healthcare professionals who met the inclusion criteria in a face-to-face manner, obtained their informed consent and then scheduled the interviews.In addition, the study team introduced the inclusion and exclusion criteria for patients to these healthcare professionals, who then referred patients who might meet the criteria to the study team.After eligibility screening by the study team, the purpose and content of the study were explained to patients who met the criteria in a face-to-face manner, and after obtaining their informed consent, the interviews were scheduled.

| Data collection
Face-to-face interviews were conducted in an independent and quiet office, and only the interviewer, recorder and interviewee were permitted to be present in the room.The interviews were conducted by H.Y., a nursing graduate student who carefully studied the pertinent methods of qualitative interview and repeatedly practised and confirmed her mastery of the skills needed to conduct qualitative interviews under the guidance of a nursing professor (XM.W.).After obtaining the participant's consent and having the informed consent form signed, the researcher initially documented the participant's basic information, such as age and time with tube/work.Then, formally begin the interview in accordance with the interview outline.
The interview outline was initially developed based on the relevant literature.Then, based on the expert's research orientation, qualifications and willingness to provide guidance, a clinical nursing expert with a senior title who specializes in surgical nursing and has some experience in qualitative studies was consulted for her opinions regarding further revisions (such as whether the interview questions were reasonable, whether they could accurately reflect the purpose of the study, and whether they should be presented in a different order).After the preinterviews with two participants, the outlines were amended to create formal outlines (see Appendix S2).
The entire interview process was audio recorded using a mobile phone.At the same time, important information, such as the participants' expression and tone were recorded in writing by GQ.P.Most importantly, during the interview, participants were not interrupted at will, the interviews remained quiet and listened actively, the order of the interview questions was adjusted according to the participant's answers and the details were pursued in a timely manner when necessary, with any unclear or mentioned crucial points being confirmed through the use of repetition, follow-up questions or counterquestions.

| Ethical considerations
This study was reviewed and approved by the Ethics Committee of the hospital (ethical review no.154, 2022).All participants participated voluntarily and signed informed consent.During the interview, participants could terminate the interview at any time.

| Reflexivity and rigour
The study team members were all female, and the team included one professor, one master of nursing and three nursing graduate students who had taken a course in qualitative research.The researchers were students and not involved in the clinical work of the ward, so no established prior relationships existed between the interviewer and the interviewees to ensure the quality of the interviews.
The study team took the following actions to guarantee the validity of the findings.During the data collection phase, interviews were conducted on the basis of a carefully revised semistructured interview outline, and the entire interview process was recorded.During the data analysis stage, the transcribed text was returned to the participants for confirmation, and two researchers immersed themselves in the data for an extended period and worked on coding and analysing the information.In addition, the researchers maintained a reflective and engaged in team discussions to avoid preunderstanding influencing the study.

Potential psychological needs
Most patients reported that carrying a drain relieved the symptoms of their disease, but it also interfered with their daily life, changed some of their habits and made them less comfortable and irritable.Some patients also developed anxiety and even experienced negative emotions, such as excessive worry about problems with their drain, a lack of selfconfidence and fear of socializing.The heavy psychological burden experienced by patients reflects their underlying psychological needs and requires attention from healthcare professionals.'Sometimes it is quite annoying to have a drain, I cannot shower comfortably, I have to sleep more carefully, and I go out less often' (P13).

Knowledge needs for disease care
Patients are generally discharged from the hospital with instructions on drain care and medication provided by healthcare professionals.
However, some patients mentioned that the discharge instructions were somewhat broad and that they would like more personalized life guidance (diet, exercise).Other patients reported feeling as if they understood what the nurses were telling them when they were discharged from the hospital but were not quite sure what to do after they were discharged.In addition, some patients realized that they still had some nursing knowledge needs when they encountered a nursing problem after discharge, such as the management of drain emergencies.These reports indirectly reflect that discharge guidance is not sufficiently comprehensive and specific and that attention should be given to facilitating patients' knowledge acquisition.'One time my drain fell out, but the doctor probably did not think about that and did not tell me, so when the tube fell out, I put it in myself and it hurt my stomach' (P1).

| Theme 3: Perception of transitional care service pathways
Patients who had experienced transitional care services exhibited some preference for the way in which transitional care services were delivered.

Preferred transitional care model for the hospital-to-home transition
In this study, it was found that most of the patients preferred receiving home care for their drains after discharge due to their financial situation.Service accessibility is also a factor considered by patients.Some community hospitals have not yet launched drain care services, and patients living in those communities must travel to the outpatient clinics of large hospitals to receive drain care, which is both time-consuming and energy-consuming.'I prefer that doctors and nurses teach me how to care for the pipes, because my home is far away from the town, and it costs some money every time' (P5).

Preferred network information guidance and telephone follow-up
The network information technology guidance method with microblogging, public numbers and other carriers is convenient and conveys visual, rich and vivid content, and the ease with which this content can be understood facilitates the majority of patients accepting follow-up care.In most cases, healthcare professionals follow more than one form of practice and need to account for patients who do not have access to the internet, so telephone followups are also acceptable to patients.'You can use the internet, we can learn on it, it is all very convenient now, otherwise we will forget after you have talked about it' (P9).

| Themes of healthcare professionals interviews
Table 4 shows the themes and codes for healthcare professionals.
Please see Appendix S3 for a supplementary table with all the quotes.

| Theme 1: Harvest and challenges in transitional care services work
Healthcare professionals described their views about transitional care from a wider perspective.

Bringing a positive emotional experience
Participants reported that they gained a sense of achievement from building harmonious relationships with their patients, implementing transitional care services for their patients, and improving drain care Trust and gratitude from patients also provide them with positive motivation.In addition, healthcare professionals believe that the process of serving patients is also a process of self-learning, through which they gain experience and improve themselves.'A patient wrote me a thanks letter before.In fact, these are what I should do, but her sincerity touched me.I will always remember this trust and strength' (N4).

Existing difficulties and challenges
Numerous participants mentioned the issue of human resources, and one healthcare worker reported having to manage multiple patients and limited time and energy, which to some extent led to a shorter time needed for the implementation of transitional care.'Human resources are a big problem, there is a lot of work every day, and sometimes I feel as if it is almost enough to do a good job in the basic operations for patients.Transitional care needs to spend more time and energy to educate and contact patients' (N9).
In addition, although a system for transitional care management is now in place and transitional care is implemented through WeChat, participants said that they found that, in practice, the transitional care process and didactic guidance needed to be further harmonized and further deepened to avoid compromising patients' grasp of knowledge.'Sometimes the patient will ask us what they should do to change the drainage tube themselves, and we will guide them.
However, we do not have uniform guidelines, and if you do not do a good job, you might get in trouble' (N2).
Currently, nursing continuity relies on the support of an information platform.The existing WeChat platform can be used to realize basic functions such as video guidance and communication, but doctors and nurses have expressed the need to develop a more complete and feature-rich information platform for the support of transitional care, and this is a challenge.'It is good to have a WeChat platform, so that patients can ask questions directly, and we can push nursing knowledge, but if I want to do more, such as monitoring the patient's postdischarge diversion, the WeChat group chat approach does not work' (N12).

| Theme 2: Expectations for future development of transitional care services
Participants expressed their expectations for future developments, as they all wanted to make transitional care better.

Hospital and departmental level
Participants would like to see more invested in human resources, which requires decision-making on the part of managers to allocate and manage human resources more appropriately.Some participants suggested that every charge nurse should be involved in transitional care.In addition, systems and norms should be improved, and team members should master the knowledge and collaborate with each other to better provide transitional care for patients.'We must review the literature, develop scientific guidelines, improve follow-up systems and processes, and pass on the right knowledge to patients and families' (N5).
As the demand for healthcare services is increasing, participants said that they would like to have a strong information platform to ensure the continuity and privacy of services to achieve information sharing, which is difficult to achieve through individual efforts alone.
'I hope that we can introduce a smarter platform to help us build personal health records for discharged patients and implement personalized management' (N10).

Social level
At present, it is mainly the nursing staff in hospitals who are responsible for implementing transitional care, and the out-ofhospital support is relatively weak.The participants expressed a desire for more social-level support in the future through community involvement, for example.It is very meaningful.'I think it is important to work with the community because the general trend is that more and more patients are being discharged with tubes.If the community develops, then the resources of the large hospital can be properly allocated, and patients can save time and energy' (N2).
Participants mentioned that if an effective hospital-community interface is to be realized, it is important to account for the reality of distance, how to effectively communicate and collaborate, and training and quality monitoring of the community staff.'The problem we are facing is now that we have some medical joint units, the patients are relatively scattered, and many units have not established contact with them' (N4).

| DISCUSSION
In this study, both patients and healthcare professionals reported having had positive experiences with transitional care.We can find one reason for this is the positive interaction between patients and healthcare professionals, who mutually support each other.The other is the reality that transitional care genuinely has helped the patient, which is the result that healthcare professionals want to achieve.
T A B L E 4 Results of healthcare professionals interviews analysis.What has been done well should be continued, and improvements are made in response to the identified problems.Negative psychological emotions, such as worry, irritability and the fear of socializing, are profound experiences of PTBD patients following their discharge from the hospital, and these experiences can seriously affect their quality of life.It is suggested that healthcare professionals should pay more attention to the psychological state of PTBD patients, which is consistent with the findings of Mo Wei's study. 20r patients with benign obstructive jaundice, PTBD can facilitate the rapid relief of jaundice and infection symptoms and provide a method for follow-up treatment. 21The relatively short time these patients had spent on the tube may have contributed to their positive attitude.However, for patients with malignant obstructive jaundice, PTBD is a palliative treatment that can only relieve obstructive jaundice but has no effect on tumours invading bile ducts and thus cannot completely the disease. 22Patients need to endure the pain of the disease itself and the discomfort caused by the drainage tube.In this study, it was found that although patients with long-term tubes have gradually become accustomed to living their lives with tubes, they also have a need for psychological care.Carrying the drainage tube for a long time causes serious interference in daily life and work, resulting in psychological disorders. 23The negative emotion of some patients is related to a lack of correct cognition regarding the pipeline, which may lead to changes in medical compliance behaviour and consequently affect treatment outcomes. 24Therefore, it is recommended that the transitional care team should strengthen the health education and humanistic care of patients, change patients' incorrect cognition, and give patients confidence and support to alleviate their adverse psychological emotions.
PTBD can successfully enable biliary decompression, but because it is an invasive intervention with potential complications, blockage, dislocation and cholangitis are often encountered in longterm catheter therapy. 25Standardized PTBD drainage tube care helps to reduce complications, ensure the effectiveness of interventional surgery and improve patients' quality of life. 21Rattanakanlaya found that the quality of discharge guidance for PTBD patients was positively correlated with their discharge readiness, and a high degree of discharge readiness indicates that patients are ready for home care, have a better grasp of the knowledge of disease pipeline nursing and have a higher compliance and self-care ability, which could effectively improve their quality of life outside the hospital. 15erefore, the transitional care team should pay attention to the quality of discharge guidance and ensure that it is provided according to the needs of patients so that patients and their families can master the nursing knowledge of drainage tubes during hospitalization and reduce the pressure of transitional care after discharge. 26However, the patient's age, education level, learning and acceptance ability, health literacy, mental state and physical condition can all affect discharge guidance. 27The feedback method is recommended for health education. 28Daoqiong Huang et al. 29  Nurses' choice of occupation is affected by salary and welfare, working hours, mode, intensity and environment.In addition to the national government strengthening the creation of nurse talent teams and the provision of welfare protection from macro policies, medical institutions should also implement reasonable human resource allocation strategies. 32 is critical that the nurses who provide care to patients have the best medical knowledge, 21 because their nursing behaviour and quality can affect patient outcomes.A national survey in the Netherlands found that nurses working in hospital gastrointestinal surgery had a low overall knowledge of PTBD placement procedures and catheter care, with half of the nurses reporting that their existing knowledge was insufficient. 33In China, a survey on PTBD drainage tube care for patients with malignant biliary obstruction in 130 hospitals showed that there were obvious deficiencies in drainage tube care, such as the fixing of biliary drainage tubes, the nursing of puncture points and the connection of drainage bags. 34

Within 24 h
after the interview, the researcher converted the recording into text, and other members of the research group checked it and returned it to the participants for reconfirmation.Two research members (H.Y. and LY.G) used Nvivo 11.0 software and thematic analysis method for analysis 19 : (1) familiarizing with data: all interview data were read in detail, noting down initial ideas; (2) generating initial codes: extract statements related to transitional care experiences and perceptions, encode significant statements and recurring ideas; (3) searching for themes: collating codes into potential themes and gathering all data relevant to each potential theme; (4) reviewing themes: checking the themes in relation to the coded extracts and the entire data set; (5) defining and naming themes: ongoing analysis to refine the specifics of each theme, generating clear definitions and names for them; (6) producing the report: select vivid and compelling excerpts, connect the analysis to research questions and literature, and produce scholarly reports of the analysis.

Finally, 13
PTBD patients from one hospital and 12 healthcare professionals from three hospitals were interviewed, and none of the participants dropped out of the interview.The duration of each interview is 10-50 min.The average age of the patient was (49.77 ± 12.51) years old, the average duration of catheterization was (7.73 ± 12.63) months, the average age of the healthcare staff was (37.25 ± 5.26) years and the average years of working in the specialty were (11.65 ± 5.46) years.Details are shown in Tables1 and 2.

3. 2 . 1 |
Theme 1: Recognition of the value of transitional care services Interviews revealed that most patients were satisfied with the transitional care services they received and that the attitude and effectiveness of the services were crucial factors.Appreciate the positive attitudes of healthcare professionals Attitude is one of the key factors influencing patient satisfaction with nursing care.The harmonious relationship between nurses and patients is conducive to the practice of nursing.Most patients reported being deeply impressed by the professional attitude of the doctors and nurses, the healthcare staff responded quickly to their questions, and this positive attitude made them feel supported.'You always have a smile, and you are very patient in helping me to change the medicine and care, I am very satisfied with your work' (P5).T A B L E 1 General data of PTBD patients (N = 13).
outcomes.'I have taken on the role of missionary and mentor in my work, and I feel that I have realized the value of my work through my own efforts' (N3).
have shown that this form of information feedback helps patients master self-care skills for PTBD drainage tubes.At the same time, the discharge guidance provided by healthcare professionals should be combined with the specific situation of patients, targeted guidance for patients and repeated self-care knowledge.Many participants in this study mentioned the problem of insufficient human resources, and reasonable human resource allocation is an important guarantee for the development of medical and healthcare activities.Nurses are now an important part of the successful implementation of transitional care. 30According to the National Nursing Development Plan (2021-2025) issued by the National Health Commission of China, 31 by the end of 2020, there were more than 4.7 million registered nurses in China, which represents an increase of 45% over those in 2015.The number of registered nurses per 1000 population reached 3.34.However, compared with the economic and social development and the growing health needs of the people, the number of nurses in China is relatively insufficient and the distribution is still uneven.
Notably, in 2022, Chinese scholars released the expert consensus on the drainage nursing of PTBD.35It is pointed out that the health education of PTBD patients should include the necessity of retaining the PTBD drainage tube, proper fixation and effective drainage, the observation and recording of drainage fluid, clamp tube nursing, skin care, diet and nutrition, activity guidance and requests for follow-up visits.Nursing managers should pay attention to the frontier progress of the discipline, apply the best evidence to the clinic and formulate optimal scientific education guidance.At the same time, the nursing staff should improve the standardized training of drainage tube nursing so that they can better educate patients and their families and ensure that drainage tubes are maintained properly following patient discharge.The state also encourages institutions to actively provide transitional care, continuously improve the quality of care and strive to build a system of nursing norms and technical standards from an evidence-based perspective that accounts for clinical needs to promote the development of high-quality nursing.31In this study, healthcare professionals mentioned that patient satisfaction and drainage tube nursing outcomes could be used to evaluate transitional care quality.These two indices fall under the result

Table 3
shows the themes and codes derived from the patient interviews.Please see Appendix S3 for a supplementary table with all the quotes.
General data of healthcare staff (N = 12).
Abbreviation: PTBD, percutaneous transhepatic biliary drainage.Benefit from transitional care servicesPreviously, patients often had problems with drain care after being discharged, and the transitional care service enabled patients to acquire relevant knowledge under the guidance of healthcare professionals, facilitating the implementation of selfcare after discharge, effectively providing physiological benefits to patients and promoting patient acceptance of the service.Moreover, the pattern of regular follow-up visits makes the patients feel psychologically satisfied.'Every time I was discharged from the hospital, you would call to determine how I was doing.With your care and help, I can take better care of myself now!' (P8).T A B L E 2 T A B L E 3 Results of patient interview analysis.