The burden of not-weighted factors - Nursing workload in a medical Intensive Care Unit

Healthcare-associated infections and nursing leadership: A systematic review

Background

Healthcare-associated infections are strictly related to healthcare practices. A head nurse stimulates and motivates nurses, boosts nurses' job performance and satisfaction, and can influence adverse event development.

Aim

To explore the relationship between healthcare-associated infections and head nurse leadership style.

Methods

A systematic review was conducted. The search was conducted from 1973 until March 2022 on PubMed, Cochrane Library, Scopus, CINAHL, Web of Science, Embase, and APA PsycInfo databases. The review followed the Joanna Briggs Institute Manual for Evidence Synthesis and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A thematic synthesis and critical appraisal of the included studies have been conducted.

Results

Eight articles were included in this review. Head nurses' leadership, supported by the organization, can positively influence the job performance and job satisfaction of nurses by reducing infection rates associated with vascular access and urinary catheters.

Discussion

Authentic and transformational nurse leadership styles can foster targeted interventions and improvements tailored to preventing and controlling healthcare-associated infections. Even if there is limited evidence, the results support that the occurrence of infections can be reduced by leadership strategies implemented by head nurses.

The comparison of the Nursing Activities Score and TrendCare to accurately measure critical care nursing workload: A prospective observational design

INTRODUCTION

Intensive care units commonly use the Nursing Activities Score (NAS) to measure nursing workload, however, some settings use TrendCare. Historically 100 NAS points reflected one nurse, however research now suggests greater than 61 NAS points per nurse increases hospital mortality.

OBJECTIVES

To determine if: 1) TrendCare accurately reflects critical care nursing workload as measured by the NAS and 2) the required nursing hours calculated by each of the scoring systems differed between indigenous and non-indigenous patients.

METHODS

Using a prospective observational design, data were collected between 9 August - 25 November 2021. Nursing workload was assessed over three shifts using TrendCare and the NAS.

RESULTS

Analysis included 183 patients and 829 TrendCare and NAS scores. The mean NAS for intensive care patients was >61 on all three shifts (morning M = 67.1 ± 18.2, afternoon M = 66.1 ± 18.1, night M = 64.0 ± 18.1). The mean NAS for high dependency patients (morning M = 46.1 ± 11.1, afternoon M 45.9 ± 11.0, night Mdn 46.1 [40.5-54.1]) identified a nurse:patient ratio of 1:2 reflected a NAS >90. The NAS and TrendCare found no difference in nursing hours between indigenous and non-indigenous patients, however higher scores for respiratory (H = 7.3, p = <.01), cardiovascular (H = 12.7, p = <.001) and renal (H = 12.7, p = <.001) support, and care for relatives and patients (H = 13.8, p = <.001) on some shifts were identified in indigenous patients.

CONCLUSION

TrendCare nursing hours likely reflect a 1:1 nurse: patient ratio for intensive care patients but likely under-estimates high dependency care nursing workload. The NAS activities highlighted some activities required more time for indigenous patients on some shifts.

IMPLICATIONS FOR CLINICAL PRACTICE

TrendCare likely reflects intensive care nursing workload but not high dependency nursing workload. A NAS of no greater than 61 points per nurse better reflects nursing workload in both the intensive and high dependency care units. Indigenous patients may require more nursing hours for nursing activities related to severity of illness.

Examination of workload perception, burnout, and perceived organizational support in emergency healthcare professionals: A structural equation model

Job stress is one of the important factors affecting employee behavior. One of the most important factors in reducing burnout caused by stress is organizational support. In this context, the aim of this study is to identify the moderating role of perceived organizational support in the effect of workload perception on burnout within the emergency healthcare professionals' universe. The data for this study were collected from 703 health professionals working in emergency health services in three major cities of Turkey. The relationships and the model of the study is analyzed by the Structural Equation Model technique. The results indicate that perceived workload is a factor that causes employee burnout, and perceived organizational support is a factor that reduces employee burnout. This study contributes to researchers and health managers by revealing the importance of workload planning and organizational activities that support employees to reduce burnout in health workers.

Determinants of increased nursing workload in the COVID-era: A retrospective analysis of prospectively collected data

BACKGROUND

COVID-19 is associated with increased nursing workload, therefore a high nurse-to-patient ratio would be required.

AIM

To analyse difference in nursing workload, as expressed with the Nursing Activities Score (NAS), between COVID-19 patients versus control patients without COVID-19 disease (NCOVID-19 group) in an Italian Extracorporeal Membrane Oxygenation (ECMO) centre.

STUDY DESIGN

Retrospective analysis of prospectively collected data, enrolling consecutive patients admitted to a general Intensive Care Unit, between 1st May 2019 and 28th February 2021. A multivariate analysis was then performed to assess if COVID-19 disease was an independent predictor of higher NAS and to assess which other factors and procedures are independently associated with increased workload.

RESULTS

We enrolled 574 patients, of which 135 (24%) were in the COVID-19 group and 439 (76%) in the NCOVID-19 group. The average NAS was higher in the COVID-19 group (79 ± 11 vs. 65 ± 15, T = -10.026; p < 0.001). Prone positioning, continuous renal replacement therapy (CRRT) and ECMO were used more frequently in the COVID-19 group. A higher fraction of patients in the COVID group showed colonization from multidrug resistant bacteria. COVID-19 group had a higher duration of mechanical ventilation and longer ICU stay. The COVID-19 diagnosis was independently associated with a higher NAS. Other independent predictors of higher NAS were the use of prone positioning and continuous renal replacement therapy (CRRT). Colonization from multidrug resistant bacteria and ECMO support were not independently associated with higher NAS.

CONCLUSIONS

The higher nursing workload in COVID-19 patients is mainly due to specific procedures required to treat the most hypoxemic patients, such as prone positioning. Colonization with multidrug resistant bacteria and ECMO support were not independently associated with a higher NAS.

RELEVANCE TO CLINICAL PRACTICE

Higher workload in COVID-19 patients was due to specific interventions, such as prone positioning and CRRT, with the related nursing activities, as continuous presence at patient's bed, mobilization, positioning and complex hygienic procedures.

From pervasive chaos to evolutionary transition: The experience of healthcare providers during the COVID-19 pandemic

AIM

The outbreak of the COVID-19 pandemic confronted healthcare providers, especially physicians and nurses, with many unprecedented changes and physical and psychological pressures. This study aimed to explore the healthcare providers' experiences providing healthcare services for patients during the COVID-19 pandemic in "Golestan, Northeast Iran".

DESIGN

Qualitative, conventional content analysis.

METHODS

A total of 13 eligible participants were recruited through the purposeful sampling method. Data were gathered using semi-structured in-depth individual interviews. Transcripts were analysed using an inductive content analysis based on the Elo and Kyngas model. The COREQ checklist was used to prepare the manuscript.

RESULTS

The analysis of the data in this study led to the development of 16 subthemes and 5 themes emerged as follows pervasive chaos, imposed difficulties, paradoxical perceptions, committed efforts, and constructive transition.

CONCLUSION

The experience of HCPs during the COVID pandemic in "Iran" showed that despite the physical, mental, emotional, and social consequences, a kind of constructive evolution and transition has also taken place in personal, professional, and organizational dimensions. It is suggested that managers while strengthening and protecting the capabilities and skills that have emerged, to reduce the tensions of HCPs, have developed programs for comprehensive support from them in physical, psychological, social, and financial dimensions.

RELEVANCE TO CLINICAL PRACTICE

It is necessary to improve inter-professional cooperation, empathy, teamwork, professional commitment, and continuous learning in crises.

Comparison of clinical characteristics and healthcare resource use of pediatric chronic and non-chronic critically ill patients in intensive care units: a retrospective national registry study

Introduction

Chronic critically ill patients (CCI) in pediatric intensive care unit (PICU) are at risk of negative health outcomes, and account for a considerable amount of ICU resources. This study aimed to (a) describe the prevalence of CCI children, (b) compare their clinical characteristics and ICU resources use with non-CCI children, and (c) identify associated risk factors of CCI.

Methods

A retrospective national registry study including 2015-2017 data from the eight Swiss PICUs of five tertiary and three regional hospitals, admitting a broad case-mix of medical and surgical patients, including pre- and full-term infants. CCI patients were identified using an adapted definition: PICU length of stay (LOS) ≥8 days and dependence on ≥1 PICU technology.

Results

Out of the 12,375 PICU admissions, 982 (8%) were CCI children and compared to non-CCI children, they were younger (2.8 vs. 6.7 months), had more cardiac conditions (24% vs. 12%), and higher mortality rate (7% vs. 2%) (p < 0.001). Nursing workload was higher in the CCI compared to the non-CCI group (22 [17-27]; 21 [16-26] respectively p < 0.001). Factors associated with CCI were cardiac (aOR = 2.241) and neurological diagnosis (aOR = 2.062), surgery (aORs between 1.662 and 2.391), ventilation support (aOR = 2.278), high mortality risk (aOR = 1.074) and agitation (aOR = 1.867).

Conclusion

the results confirm the clinical vulnerability and the complexity of care of CCI children as they were defined in our study. Early identification and adequate staffing is required to provide appropriate and good quality care.

Breaking bad news in medical services: a comprehensive systematic review

OBJECTIVE

This study was performed with the aims of screening the previous studies on breaking bad news in all medical wards.

METHODS

Eligible observational studies were selected. The quality of the studies was assessed using the STROBE checklist. The findings were reported using Garrard's table. All the stages of the present study were performed in terms of the PRISMA statement.

RESULTS

Totally, 40 articles were included in the study and 96 items were extracted. The results show that breaking bad news is a recipient-centered process. Respect, empathy, and support were reported. The news presenters are better to use guidelines based on evidence-based findings. It is suggested that the presenter should use simple and understandable content. Moreover, suitable time and space are important to present the news. The results show the importance of paying enough attention to the emotions of the recipient and the need to provide support after breaking bad news.

CONCLUSION

The recipient must be the center of the programs. It is necessary to pay attention to the characteristics of the news presenter, the news content, and finally the support.Practice Implication: Understand the recipient, trained presenter, and use of the evidence-based results, improve the breaking bad news outcome.

Anxiety and work overload perception levels of primary healthcare professionals during the COVID-19 pandemic

BACKGROUND

The coronavirus disease (COVID-19) has greatly affected healthcare workers at the physical and psychosocial level. In this process, primary healthcare workers have taken the most active role by taking part in the filiation groups.

OBJECTIVE

This study aimed to determine the anxiety and workload perception level of primary healthcare workers during the COVID-19 pandemic.

METHODS

This was a cross-sectional study. An online survey was conducted among 197 healthcare workers. Personal Information Form, the Coronavirus Anxiety Scale and Work Overload Scale were used as data collection tools in the research. Independent Two-Sample T-Test, One-Way Analysis of Variance, Mann-Whitney U test and Kruskal Wallis test were used to evaluate the data. Moreover, the relationships between the scales were evaluated with Pearson correlation analysis and simple regression analysis.

RESULTS

The median total score of the Coronavirus Anxiety Scale of healthcare workers was 3.0, and the mean score of the Work Overload Scale was 37.89±7.47. It was found that there was a correlation between the Coronavirus Anxiety and the Work Overload Scales and 21.0% of the variance changes in the Work Overload Scale were affected by coronavirus anxiety.

CONCLUSION

It was determined that the level of coronavirus anxiety affects the perception of workload. Therefore, it is recommended that work plans should be made considering this situation.

"I Didn't Want My Baby to Pass, But I Didn't Want Him Suffering Either": Comparing Bereaved Parents' Narratives With Nursing End-of-Life Assessments in the Pediatric Intensive Care Unit

Little is known about how nursing care at the end of a child's life impacts long-term parental bereavement. We aimed to explain, contextualize, and examine comparisons between quantitative trends in children's end-of-life care and parents' qualitative perceptions. We used a mixed methods design, combining quantitative data from the RESTORE clinical trial with qualitative interviews with bereaved parents. Patients who died during RESTORE were included in quantitative analyses. A subset of their parents was interviewed 7 to 11 years later. The quantitative analyses included 104 children. Eight parents were interviewed; 4 had a child die after cancer, and 4 had a child die after a complex chronic illness. Quantitatively, patients' pain and sedation scores were generally comfortable. Children died with multiple invasive devices in place. Parents' descriptions of their child's comfort and critical care requirements differed by illness trajectory (cancer, complex chronic illness). Parents' memories of their child's suffering aligned with peaks in clinical scores, rather than averages. Invasive devices and equipment altered parents' ability to make meaningful final memories with the dying child. Pediatric intensive care clinicians may need to broaden how they attend to dying children's pain and corresponding parental distress, as parents' memories of their dying child's suffering persist for years.

Defining nursing workload predictors: A pilot study

Aim

To explore predictors of perceived nursing workload in relation to patients, nurses and workflow.

Background

Nursing workload is important to health care organisations. It determines nurses' well‐being and quality of care. Nevertheless, its predictors are barely studied.

Methods

A cross‐sectional prospective design based on the complex adaptive systems theory was used. An online survey asked nurses to describe perceived workload at the end of every shift. Data were gathered from five medical‐surgical wards over three consecutive weeks. We received 205 completed surveys and tested multivariate regression models.

Results

Patient acuity, staffing resources, patient transfers, documentation, patient isolation, unscheduled activities and patient specialties were significant in predicting perceived workload. Nurse‐to‐patient ratio proved not to be a predictor of workload.

Conclusions

This study significantly contributed to literature by identifying some workload predictors. Complexity of patient care, staffing adequacy and some workflow aspects were prominent in determining the shift workload among nurses.

Implications for nursing management

Our findings provide valuable information for top and middle hospital management, as well as for policymakers. Identification of predictors and measurement of workload are essential for optimizing staff resources, workflow processes and work environment. Future research should focus on the appraisal of more determinants.

The lived experiences of frontline nurses during the coronavirus disease 2019 (COVID-19) pandemic in Qatar: A qualitative study

AIM

This study aims to explore the lived experiences of frontline nurses providing nursing care for COVID-19 patients in Qatar.

DESIGN

Qualitative, Phenomenological.

METHODS

Nurses were recruited from a designated COVID-19 facility using purposive and snowball sampling. The participants were interviewed face-to-face using semi-structured interview questions from 6 September-10 October 2020. The interviews were transcribed and analyzed using Colaizzi's phenomenological method.

RESULT

A total of 30 nurses were interviewed; (76.7%) were deployed for >6 months. Three major themes were drawn from the analysis: (a) Challenges of working in a COVID-19 facility (subthemes: working in a new context and new working environment, worn out by the workload, the struggle of wearing protective gear, fear of COVID-19, witnessing suffering); (b) Surviving COVID-19 (subthemes: keeping it safe with extra measures, change in eating habits, teamwork and camaraderie, social support); and (c) Resilience of Nurses (subthemes: a true calling, a sense of purpose).

The Effect of Organizational Justice on Job Performance and the Mediating Role of Job Satisfaction: A Study on Nurses

This study aims identifying the effects of nurses' perceptions of organizational justice on their performance and to test the mediating role of job satisfaction. This is a cross-sectional study. This study conducted with 374 nurses working hospitals. The research model was tested using structural equation modeling and the bootstrap technique. Organizational justice has been found to have a significant impact on job performance and job satisfaction. Job satisfaction had a partial mediating role. The results of this study could guide the more effective and efficient use of human resources in nursing management and contribute to the literature of health and nursing management.

Hemoadsorption cartridge and coronavirus disease 2019 infections: A case report and brief literature review

The cytokine storm has been frequently reported to occur in patients with severe coronavirus disease 2019 (COVID-19). Data from the literature suggest that elevated levels of inflammatory mediators, such as interleukin (IL)-6, IL-8, and tumor necrosis factor, indicate a severe course or the fatality of the disease. Several therapeutic options have been employed to treat critically ill patients, including hemoadsorption of inflammatory mediators. We here present a case of severe acute respiratory syndrome caused by COVID-19 and acute renal failure. The patient was admitted to our intensive care unit and treated with mechanical ventilation, renal replacement therapy, and hemoadsorption to reduce the cytokine release syndrome, which plays a fundamental role in the clinical presentation of COVID-19 patients. We also discuss the potential advantages of reducing cytokine plasma levels using a hemoadsorption cartridge.

Mapping nursing interventions using the Therapeutic Intervention Scoring System in bloodless liver transplantations

BACKGROUND

The Simplified Therapeutic Intervention Scoring System adapted to liver transplantation by King's College Hospital rank 138 activities to determine the nursing workload, diagnostic, monitoring and therapeutic needs.

OBJECTIVES

To evaluate nursing activities of "King's-TISS" score grouped in organ systems and nurse patient ratio in the perioperative 48 hours of blood product free liver transplantations (LT).

METHODS

The "King's-TISS" score's were analysed by nursing procedures and grouped, scored according to organ systems. The nursing workloads were studied during LT (T1), on arrival on the ICU (T2) and 12-24-48 hours after LT (T3-T4-T5).

RESULTS

The total of "King's-TISS" score points were decreased by ≥20% daily (p = 0.001). The mean score of 104 ± 3.5 points (CI:104-105) during LT decreased to 84.7 ± 12 points (CI:83-86) in 48 hours (T5). The "metabolic" and "haemostasis" points increased (p = ).01), the "immunology" points unchanged (T2-T5) postoperatively. A slight decrease was observed in case of "basic nursing care", "monitoring", "neurologic support", "renal support" and "cardiovascular support" points (T2-T5, p < .01). The "invasive intervention" and "ventilatory support" points strongly decreased (T2-T5, p < .001). One "King's-TISS" point was found to equal 7.4 minutes with a nurse patient ratio of 2:1 intraoperatively and 1:1 postoperatively.

CONCLUSION

Absence of blood product administration in LT decreases the total and organ specific workload, except the metabolic, haemostasis, immunology and basic support requirement. It was not within the scope of the King's-TISS score to analyse the application of viscoelastic haemostasis test and coagulation factor concentrate administration.

Adverse events during nursing care procedure in intensive care unit: The PREVENIR study

OBJECTIVES

Intensive care unit patients undergo several nursing care procedures (NCP) every day. These procedures involve a risk for adverse events (AE). Yet, their prevalence, intensity, and predisposing risk factors remain poorly established. The main objective of the study was to measure the incidence and severity of NCP related AE.

DESIGN

This prospective observational multicentre study was conducted in 9 ICUs. All NCP were recorded for four consecutive weeks. For each NCP, the following were collected: patients' baseline characteristics, type of NCP, characteristics of the NCP, AE and therapeutic responses.

RESULTS

5849 NCP occurred in 340 patients. Among the 340 patients included, 292 (85.9%) were affected by at least one AE, and 141 (41.5%) by an SAE during a NCP. Thirty % of NCP were associated with at least one AE: hemodynamic AE in 17.1%, respiratory AE in 13.6%, agitation and pain (3.7% and 3.3%). Eight invasive devices were accidentally removed. Severe Adverse Events (SAE) occurred in 5.5% of NCP. The main risk factor associated with SAE was pain/agitation at the beginning of the NCP.

CONCLUSION

AE are frequent during NCP in ICU. We identified several risk factors, some of them preventable, that could be considered for the development of recommendations for the nursing care of critically ill patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02881645.

Keyboard Contamination in Intensive Care Unit: Is Cleaning Enough? Prospective Research of In Situ Effectiveness of a Tea Tree Oil (KTEO) Film

After the SARS-CoV-2 pandemic, disinfection practices and microbial load reduction have become even more important and rigorous. To determine the contamination of keyboard surface and the relative risk to transfer healthcare-associated pathogens to susceptible patients, as it frequently happens in Intensive Care Unit (ICU), a standard keyboard (SK), a cleanable keyless keyboard (KK) with smooth surface and a standard keyboard coated with a 3 M Tegaderm^® film added with active essential oil (tea tree oil) (KTEO) were tested. S. aureus, including MRSA strains, were detected in ICU, with values ranging from 15% to 57%. Gram negative strains belonging to the Enterobacteriaceae family were also found with values ranging from 14% to 71%. Similar Gram positive and Gram negative strains were found on all surfaces, but with low percentage, and only environmental bacteria were detected using the settling plates method. The Microbial Challenge Test performed on KTEO showed high rates of decrease for all the pathogens with statistical significance both at 24 and 48 h (p = 0.003* and p = 0.040*, respectively). Our results suggest that the use of KTEO may be a feasible strategy for reducing the transmission of pathogens in health care setting and may be complementary to surface cleaning protocols.

The ratio of PACU length-of-stay to surgical duration: Practical observations

BACKGROUND

Operating room (OR) and post-anesthesia care unit (PACU) activity are closely linked since the number, type, and sequence of surgeries influence subsequent PACU activity. We aimed to explore the relationship between duration-of-surgery (DOS) and PACU length-of-stay (LOS), the PACU-LOS:DOS ratio, since it is among the determinants of the number of PACU beds and nurse staffing required to insure efficient egress of patients from the OR.

METHODS

PACU-LOS:DOS ratio was examined using retrospective data from a tertiary medical center's surgical information system (Phase 1) and prospectively collected data from a convenience sample of post-operative patients (Phase 2).

RESULTS

Phase 1 included 17 047 patients, the majority (73%) with PACU-LOS:DOS ratios >1.0, indicating PACU-LOS longer than DOS. Median PACU-LOS was 117 minutes, median DOS was 80 minutes, and median PACU-LOS/DOS ratio was 1.5. PACU-LOS showed greater variability than DOS because of extended PACU stays. Phase 2 (n = 2054) confirmed Phase 1 results (median PACU-LOS/DOS ratio - 1.8). In both phases at a DOS of >130 minutes PACU-LOS/DOS ratio became <1.0. In 24% of Phase 2 patients PACU-LOS was prolonged because of administrative issues. Post-operative, more than pre- and intra-operative, measurements influenced PACU-LOS.

CONCLUSIONS

The PACU-LOS/DOS ratio proved useful for demonstrating interactions between 2 central components of the surgical system. The many patients with PACU-LOS:DOS ratios >1.0 provides objective evidence for the number of PACU beds exceeding the number of ORs.