Making Discharge Red-Flag Instructions Actionable After Intracranial Aneurysm Treatment: A Cognitive Interviewing Study with Older Adults, Caregivers, and Nurses
- 1Department of Neurosurgery
Abstract
Zeyue Sun, Di Chen, Wenqian Huang, Yan Song, Shanshan Jiang, Xujia Zhai, Tao Liu, Wei Zhu Department of Neurosurgery, Nanjing Drum Tower Hospital, Nanjing, Jiangsu, People’s Republic of ChinaCorrespondence: Wei Zhu, Department of Neurosurgery, Nanjing Drum Tower Hospital, Nanjing, Jiangsu, People’s Republic of China, Email [email protected]: To examine how adults aged 65 years or older and their primary caregivers interpreted and intended to act on discharge red-flag instructions after intracranial aneurysm treatment, explore neurosurgical nurses’ perspectives on recurrent discharge communication problems, and iteratively refine the instructions for safer transitional care.Patients and methods: This single-center qualitative study used cognitive interviewing in a tertiary neurosurgical unit in China. Twenty-four older patients and 20 primary caregivers completed cognitive interviews across two iterative rounds; eight neurosurgical nurses completed separate contextual interviews. Think-aloud and verbal probing assessed comprehension and intended action. Framework Method analysis of round 1 informed revisions tested with new participants in round 2.Results: Four high-risk communication problems were identified: under-recognition of gradual neurological deterioration, ambiguity created by clinical wording, difficulty mapping symptoms to escalation pathways, and patient–caregiver disagreement about action. Subtle signs, including progressive drowsiness, mild speech change, repeated vomiting, and incomplete limb weakness, were often normalized. Revisions used observable symptom descriptions, explicit action cues, and caregiver-directed prompts. Round 2 suggested fewer recurring comprehension problems and closer alignment between intended responses and clinical intent, although blood pressure guidance remained challenging for some participants.Conclusion: Standard red-flag instructions may not be sufficiently actionable for older adults and caregivers after intracranial aneurysm treatment. Cognitive interviewing can support clearer, caregiver-inclusive discharge tools reinforced by nurse-led teach-back.Plain Language Summary: After treatment for a brain aneurysm, older people and their families must know which changes can be watched at home and which require urgent help. We asked older patients and their primary caregivers to explain routine warning-sign instructions in their own words and describe what they would do. Nurses who routinely provided discharge teaching were also interviewed. Participants usually recognized dramatic emergencies, but subtle changes—such as becoming progressively sleepier, speaking more slowly, vomiting repeatedly, or developing partial weakness—were often mistaken for normal recovery or aging. We revised the instructions by using observable descriptions, pairing each warning sign with a clear action, and speaking directly to caregivers. A second round of interviews indicated that the revised instructions were easier to interpret, although blood pressure advice still caused uncertainty. These findings support a short action sheet and nurse-led teach-back as practical ways to make discharge communication safer. The study assessed understanding and intended action; it did not test whether the revised material reduces emergency visits, delayed care, or readmission.Keywords: cognitive interviewing, discharge communication, intracranial aneurysm, older adults, caregivers, transitional care
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BibTeX
@article{sun2026making,
title = {{Making Discharge Red-Flag Instructions Actionable After Intracranial Aneurysm Treatment: A Cognitive Interviewing Study with Older Adults, Caregivers, and Nurses}},
author = {Sun Z and Chen D and Huang W and Song Y and Jiang S and Zhai X and Liu T and Zhu W},
journal = {Journal of Multidisciplinary Healthcare},
year = {2026},
month = nov,
url = {https://www.dovepress.com/making-discharge-red-flag-instructions-actionable-after-intracranial-a-peer-reviewed-fulltext-article-JMDH},
note = {CC BY},
}
RIS
TY - JOUR
TI - Making Discharge Red-Flag Instructions Actionable After Intracranial Aneurysm Treatment: A Cognitive Interviewing Study with Older Adults, Caregivers, and Nurses
AU - Sun Z
AU - Chen D
AU - Huang W
AU - Song Y
AU - Jiang S
AU - Zhai X
AU - Liu T
AU - Zhu W
PY - 2026
DA - 2026/11/08
JO - Journal of Multidisciplinary Healthcare
UR - https://www.dovepress.com/making-discharge-red-flag-instructions-actionable-after-intracranial-a-peer-reviewed-fulltext-article-JMDH
AB - Zeyue Sun, Di Chen, Wenqian Huang, Yan Song, Shanshan Jiang, Xujia Zhai, Tao Liu, Wei Zhu Department of Neurosurgery, Nanjing Drum Tower Hospital, Nanjing, Jiangsu, People’s Republic of ChinaCorrespondence: Wei Zhu, Department of Neurosurgery, Nanjing Drum Tower Hospital, Nanjing, Jiangsu, People’s Republic of China, Email [email protected]: To examine how adults aged 65 years or older and their primary caregivers interpreted and intended to act on discharge red-flag instructions after intracranial aneurysm treatment, explore neurosurgical nurses’ perspectives on recurrent discharge communication problems, and iteratively refine the instructions for safer transitional care.Patients and methods: This single-center qualitative study used cognitive interviewing in a tertiary neurosurgical unit in China. Twenty-four older patients and 20 primary caregivers completed cognitive interviews across two iterative rounds; eight neurosurgical nurses completed separate contextual interviews. Think-aloud and verbal probing assessed comprehension and intended action. Framework Method analysis of round 1 informed revisions tested with new participants in round 2.Results: Four high-risk communication problems were identified: under-recognition of gradual neurological deterioration, ambiguity created by clinical wording, difficulty mapping symptoms to escalation pathways, and patient–caregiver disagreement about action. Subtle signs, including progressive drowsiness, mild speech change, repeated vomiting, and incomplete limb weakness, were often normalized. Revisions used observable symptom descriptions, explicit action cues, and caregiver-directed prompts. Round 2 suggested fewer recurring comprehension problems and closer alignment between intended responses and clinical intent, although blood pressure guidance remained challenging for some participants.Conclusion: Standard red-flag instructions may not be sufficiently actionable for older adults and caregivers after intracranial aneurysm treatment. Cognitive interviewing can support clearer, caregiver-inclusive discharge tools reinforced by nurse-led teach-back.Plain Language Summary: After treatment for a brain aneurysm, older people and their families must know which changes can be watched at home and which require urgent help. We asked older patients and their primary caregivers to explain routine warning-sign instructions in their own words and describe what they would do. Nurses who routinely provided discharge teaching were also interviewed. Participants usually recognized dramatic emergencies, but subtle changes—such as becoming progressively sleepier, speaking more slowly, vomiting repeatedly, or developing partial weakness—were often mistaken for normal recovery or aging. We revised the instructions by using observable descriptions, pairing each warning sign with a clear action, and speaking directly to caregivers. A second round of interviews indicated that the revised instructions were easier to interpret, although blood pressure advice still caused uncertainty. These findings support a short action sheet and nurse-led teach-back as practical ways to make discharge communication safer. The study assessed understanding and intended action; it did not test whether the revised material reduces emergency visits, delayed care, or readmission.Keywords: cognitive interviewing, discharge communication, intracranial aneurysm, older adults, caregivers, transitional care
SN - 1178-2390
ER -