Outcomes sensitive to critical care nurse staffing levels: A systematic review

Association between Nurse Continuity and Mortality in the Intensive Care Unit

Rationale: Continuity of nursing care is highly valued in the intensive care unit (ICU), but its impact on patient outcomes remains unclear. Objectives: To investigate the relationship between nurse continuity and mortality among ICU patients. Methods: We performed a retrospective cohort study using electronic health records from 38 ICUs across 18 hospitals between 2018 and 2020. Cumulative nurse continuity was defined at the shift level as the proportion of 12-hour shifts in which the patient received care from a nurse who had previously provided care to them, up to and including the present shift. Employing a landmark analysis framework, we used logistic regression to assess the relationship between in-hospital mortality and cumulative nurse continuity at each shift, adjusting for potential confounders. Results: The study included 47,564 ICU patients. In-hospital mortality was 10.4%. Average cumulative nurse continuity increased from 10.2% at shift 3 to 34.2% at shift 14. In the regression models, increasing cumulative nurse continuity was associated with a modest but statistically significant increase in mortality in some but not all shifts. The results were robust to sensitivity analyses, including limiting the cohort to patients receiving mechanical ventilation, excluding patients admitted during the COVID-19 pandemic, using different measures of continuity, and treating continuity as a time-varying covariate using proportional hazards regression. Conclusions: Nurse continuity was not associated with lower mortality and may lead to increased mortality in some settings. Further research is needed to understand the mechanisms underlying the association between nurse continuity and ICU outcomes.

Intensive care unit nurses' redeployment experiences during the COVID-19 pandemic: A qualitative study

BACKGROUND

The pandemic response required the large-scale redeployment of nurses to support the care of patients with COVID-19. Surveys of staff and analysis of staff feedback indicated that the frequent redeployment of intensive care unit (ICU) registered nurses (RNs) led to dissatisfaction and contributed to voluntary reductions in hours and increased intentions to resign. Whilst much is understood about the redeployment of non-ICU RNs into ICUs to support patient care during periods of high demand, less is known about ICU RNs' experiences of being redeployed to general wards. ICU RNs are often required to work in other areas to cover staff shortages within the organisation when ICU beds are available.

AIM

The aim of this study was to explore ICU RNs' experiences of redeployment to hospital wards during 2021 and 2022.

METHODS

A descriptive qualitative study using semi-structured interviews with 26 ICU RNs was conducted at three hospitals within a major health service in Melbourne, Australia. Participants were interviewed in July 2023. Transcribed audio recordings of interviews were analysed using reflexive thematic analysis.

RESULTS

Six major themes and 12 subthemes were constructed from the data: (i) risk (subthemes: absenteeism, bad for patients-ICU and ward); (ii) choice (subthemes: no choice, security of the ICU); (iii) lost (subthemes: lack of orientation, unfamiliar everything); (iv) distress (subthemes: clinical and emotional stress); (v) a number (subthemes: undervalued, unfair); and (vi) positive perspectives (subthemes: good experience, has to happen, helping out).

CONCLUSION

ICU RNs' experiences of redeployment out of the ICU were predominantly negative. However, positive aspects were noted regarding the support of colleagues during staff shortages and the opportunity to provide care to patients. The findings highlight the risks associated with redeployment and its impact on both the ICU and the broader health service. Suggested strategies include implementing through orientation practices, adopting a sustainable team nursing approach, and prioritising staff wellbeing.

Punctuated Entropy in the ICU During COVID-19: Team Nursing and Burnout

BackgroundThe novel demands on hospital capacity arising from the COVID-19 pandemic revealed already-existing systemic weaknesses. Intensive care units experienced a sustained surge capacity and were forced to introduce modified standards of care and practices.PurposeIn this article we use punctuated entropy as a conceptual lens to reveal the impact of the COVID-19 pandemic on Ontario hospitals by drawing attention to the cumulative impact of repeated disaster events on their capacity to recover.MethodsThis qualitative instrumental case study took place at a Medical-Surgical Intensive Care Unit in a university-affiliated teaching community hospital in a large urban center in Ontario, Canada. Twelve healthcare professionals from the ICU participated in in-depth semi-structured interviews.ResultsIn-depth interviews with healthcare providers revealed an already-vulnerable system and the disproportionate impact of COVID-19 on the nursing workforce, compounding pre- burnout and compassion injury.ConclusionThe structure of intensive care and the dynamics of collaborative practices within ICUs are subject to continual reconfiguration, potentially leading to punctuated entropy - a permanent state of a lack of capacity to recover. Disaster recovery planning in healthcare services delivery should not be focussed simply on navigating the 'temporary' effects of a single event, but rather on how the event interacts with the already existing 'pathological' state of the healthcare system. In this way solutions to longitudinal systemic problems in ICU healthcare delivery can be anticipated and plans for mitigation can be put in place.

Factors Associated With Intent to Leave the Nursing Profession in the United States: An Integrative Review

The ongoing regional nursing shortages in the United States, exacerbated by the COVID-19 pandemic, compromise patient safety and quality. Additionally, an aging workforce coupled with an aging population requiring more nursing care services limits organizations' ability to adequately staff their facilities. Nurses' turnover from the profession has been studied less than organizational turnover, thus, the purpose of this integrative review is to identify factors associated with intention to leave the nursing profession in the United States. Using Whittemore and Knafl's (2005) guidelines for integrative review methods, we conducted systematic searches in CINAHL, PubMed, and Web of Science in July 2024. There were 39 peer-reviewed studies that met inclusion criteria. Synthesis of findings resulted in four individual and four work-level themes associated with intent to leave the nursing profession. Individual themes included individual beliefs, health and wellbeing, individual work experiences, and career stability. Work-level themes included job characteristics, job demands/workload, resources and support, and work environment. Notably, job-level factors (i.e., workload, work environment, and support) were associated with professional turnover intention, which suggests that nurses do not believe their experiences will improve at another nursing job. Gaps in the literature include studies with nationally representative samples, studies using validated measures of health, and qualitative studies conducted with the aim of understanding why nurses want to leave the profession. To promote retention of nurses at the professional and organizational level, organizations should measure and modify relevant job-level factors, and the protection of nurses' wellness should be a top organizational priority.

National survey evaluating the introduction of new and alternative staffing models in intensive care (SEISMIC-R) in the UK

OBJECTIVE

To report on the findings from a national survey of UK intensive care units (ICUs) exploring nurse staffing models currently in use and changes since COVID-19.

DESIGN

A survey was designed and distributed using a web-based platform to senior unit leads via Intensive care national audit & research centre contacts.

PARTICIPANTS

Senior nurses representing the 331 National Health Service adult ICUs across the UK (across 231 hospitals/155 trusts), including the Channel Islands and Isle of Man.

OUTCOME MEASURES

A 15-item survey.

RESULTS

A total of 196 survey responses representing 300 units, majority general and single units, resulting in a 90.6% unit-level response rate. ICU unit characteristics included the average number of total, level 3 and level 2 critical care beds of 26.36 (SD=21.48), 15.67 (SD=15.33) and 10.96 (SD=8.86), respectively. Most units reported nurse to patient ratios compliant with national guidelines and service specifications. Post-COVID-19 changes to ICU nurse staffing establishments were reported by 44% respondents, including increases in non-registered staff. However, limited data were provided regarding decision-making around and changes to bedside allocation of nurses since COVID-19.

CONCLUSIONS

Increased numbers and use of non-registered staff within the ICU is indicative of an alternative staffing model to address nursing shortages. However, more research is needed to understand how this staffing group is being used compared with, and alongside, registered nurses.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov: NCT05917574.

Nurse Staffing Configurations and Nurse Absence Due to Sickness

Importance

Rates of work-related stress and sickness absence are high among nurses. The consequences of sickness absence are severe for health systems' efficiency and productivity.

Objective

To examine the association between nurse staffing configurations and sickness absence in hospital inpatient unit nursing teams.

Design, Setting, and Participants

This retrospective longitudinal case-control study using routinely collected hospital data among 4 general acute care hospitals in England examined 18 674 registered nurses (RNs) and nursing support (NS) staff working in 116 hospital units. Data were analyzed from April 1, 2015, to February 29, 2020.

Exposure

Nursing team skill mix, temporary staffing hours, understaffing, proportion of long shifts (≥12 hours) worked, and full-time or part-time work status in the previous 7 days.

Main Outcome and Measure

The main outcome was the number of episodes of sickness absence, which was defined as a sequence of sickness days with no intervening days of work.

Results

There were 2 690 080 shifts and 43 097 sickness episodes. The incident rates for starting a sickness episode were 2.0% for NSs and 1.4% for RNs. In total, there were 18 674 members of staff; 2 188 562 (81.6%) were shifts by staff classified as working full time and 493 400 (18.4%) by staff classified as working part time. A skill mix composed of more RNs was associated with a 2% reduction in the odds of RN sickness absence for each 10% change in the proportion of RN hours (odds ratio [OR], 0.98; 95% CI, 0.96-0.99). Moving from the lower quartile skill mix (ie, approximately 55% of the nursing hours worked by RNs) to the upper quartile (ie, approximately 75% of the nursing hours worked by RNs) was associated with a 4% reduction in odds of sickness absence. Working only long shifts in the prior 7 days was associated with a 26% increase in the odds of sickness absence for RNs compared with working no long shifts (OR, 1.26; 95% CI, 1.19-1.33). Part-time work for RNs was associated with higher sickness absence (OR, 1.09; 95% CI, 1.03-1.15). For RNs, there was a significant interaction between part-time work and RN understaffing, whereby short staffing in the previous week increased sickness absence for full-time staff but not among those working part time. NS understaffing was not associated with sickness absence for any staffing group.

Conclusions and Relevance

This retrospective case-control study found that exposure to RN understaffing increased the risk of sickness absence in nursing teams. Adverse working conditions for nurses, already known to pose a risk to patient safety, may also create risks for nurses and the possibility of further exacerbating staff shortages.

"Scheduling Is Everything": A Qualitative Descriptive Study of Job and Schedule Satisfaction of Staff Nurses and Nurse Managers

BACKGROUND

Shift work and scheduling are major contributors to occupational stress for nurses, leading to job dissatisfaction and risk of turnover. Nurse scheduling processes are complex, as they are dynamically linked to nurse staffing and patient demand.

OBJECTIVE

This study sought to describe barriers and facilitators influencing job and scheduling satisfaction among staff nurses and nurse managers.

METHODS

We used a qualitative descriptive design. The sampling frame included staff nurses and nurse managers employed at an urban academic medical center. Participants (N = 16) completed individual semi-structured Zoom interviews from August 2023 to February 2024, which were audio recorded and transcribed. Data were analyzed using content analysis.

RESULTS

The overarching theme identified was "Scheduling is everything," reflecting the importance of scheduling for nurses' satisfaction in and outside of work. Both staff nurses and managers identified tensions between scheduling for patient care needs (e.g., adequate staffing) and scheduling to optimize staff needs (e.g., health, sleep). They also identified staffing shortfalls as a contributor to these scheduling tensions. Staff nurses reported that scheduling challenges compromised their health and well-being, caused work-family conflict, and influenced turnover intentions. Facilitators of scheduling satisfaction included scheduling flexibility, autonomy, and equity. Participants also provided pragmatic ideas for improving scheduling processes.

CONCLUSIONS

Our study explored perspectives on job and scheduling satisfaction through the lens of both staff and managers. Scheduling challenges contribute to nurses' job dissatisfaction and turnover intentions. By increasing scheduling flexibility, equity, and integrating nurse-led innovations into the scheduling process, healthcare organizations can potentially increase nurse retention.

Comparisons of nursing hours and nurse-to-patient ratios required for patients with mechanical ventilation, CRRT, and ECMO in intensive care units: A cross-sectional study

OBJECTIVES

To examine nurse staffing requirements in intensive care units (ICUs) for mechanical ventilation (MV), continuous renal replacement therapy (CRRT), extracorporeal membrane oxygenation (ECMO), and their combinations, and analyze the effects of these procedures on staffing requirements across different types of ICU stay.

METHODS

A cross-sectional study was conducted to analyze data from patients discharged from adult ICUs at a tertiary hospital in Seoul, South Korea, between 2022 and 2023. Staffing requirements were evaluated using nursing hours per patient day (NHPPD) and nurse-to-patient ratios. Each ICU day was categorized into one of eight procedure groups: none of three procedures, one-procedure (MV, CRRT, or ECMO), two-procedure (MV & CRRT, MV & ECMO, or CRRT & ECMO), and three-procedure (MV, CRRT, & ECMO) groups. The impacts of these groups on NHPPD were analyzed using multilevel regression models.

RESULTS

Among a total of 51,226 ICU days from 8,541 patients, the MV group accounted for the largest proportion of ICU days (44.4%), followed by the no-procedure group (38.2%). The overall NHPPD was 14.8 h, with a nurse-to-patient ratio of 1:1.6. The no-procedure group had the lowest NHPPD (12.8 h), while the three-procedure group had the highest (18.9 h). The overall NHPPD was highest on continuing-stay days, whereas two- and three-procedure groups tended to have the highest NHPPD on admission days. In multiple regression analyses, the three-procedure group exhibited the greatest increase in NHPPD (4.94 h), followed by the MV & CRRT group (4.42 h) and the MV & ECMO group (3.28 h), compared to the no-procedure group.

CONCLUSIONS

Staffing requirements varied among procedure groups and types of ICU stay. The NHPPD for combined procedures exceeded the sum of the NHPPD for the individual procedures.

IMPLICATIONS FOR CLINICAL PRACTICE

Staffing requirements should be tailored to meet the increasing patient needs resulting from procedural complexity.

Insights from the top-cited papers in the critical care nursing literature: A bibliometric and visualized analysis

BACKGROUND

Highly cited papers in critical care nursing can offer valuable insights for all stakeholders engaged in the research process by highlighting key research trends, guiding resource allocation and shaping future research priorities.

AIM

To gain insights from the top-cited papers in the top critical care nursing journals.

STUDY DESIGN

This was a bibliometric analysis of the top-cited papers in the top critical care nursing journals as reported by the Journal Citation Report 2023-released in June 2024. Data were tabulated and visualized using Microsoft Excel and the VOSviewer software.

RESULTS

Forty papers from the top four critical care nursing journals (Intensive and Critical Care Nursing [ICCN], Nursing in Critical Care [NICC], Australian Critical Care [ACC] and American Journal of Critical Care [AJCC]) were analysed. Half of the analysed papers were related to the COVID-19 pandemic, and mental health was the most addressed theme (n = 11 papers). Papers from the ICCN featured contributions from 17 countries, the highest among the journals analysed, followed by NICC, with contributions from 11 countries. Articles received more citations than reviews (median [interquartile range]: 18 [9-23] vs. 8 [8-11.5]), and open-access papers were cited about twice those published under a subscription model (19 [16-31] vs. 9 [8-15]). In ICCN, 9 of the 10 analysed papers were published open access compared with 3 in NICC and ACC and 2 in AJCC.

CONCLUSIONS

The identified themes in this paper underscore the dynamic nature of the field of critical care nursing and the ongoing efforts to address key challenges in critical care nursing practice and health care delivery. Publishing open-access articles on trending topics and collaborating internationally seem to be effective approaches for gaining more citations.

RELEVANCE TO RESEARCH

Understanding these prevalent themes has significant implications for guiding research priorities, informing clinical practice, shaping policy and improving patient outcomes. Academic journals need to encourage increasing the representation of researchers from the Global South in both journals' editorial boards and submissions to the journals.

Predicting nursing workload in digestive wards based on machine learning: A prospective study

BACKGROUND

The process of assessing and allocating nursing staff, as well as evaluating performance, relies heavily on nursing workload, which is strongly associated with patient safety outcomes. Nevertheless, most previous studies have utilized cross-sectional data collection methods, which limit the precision of workload prediction. Static workload models do not incorporate longitudinal changes in influential factors, potentially resulting in delayed or erroneous nursing management decisions and ultimately causing imbalances in nurses' workload.

AIM

To employ machine learning algorithms to facilitate the dynamic prediction of nursing workload on the basis of patient characteristics.

METHODS

This prospective cohort quantitative study was conducted between March 2019 and August 2021 in two general hospitals located in China. Data on the characteristics of 133 patients over the course of 1339 hospital days, as well as direct nursing time, were collected. A longitudinal investigation of nursing workload was carried out, applying multiple linear regression to identify measurable factors that significantly impact nursing workload. Additionally, machine learning methods were applied to dynamically predict the nursing time needed for each patient.

RESULTS

The mean direct nursing workload varied greatly across hospitalizations. Significant factors contributing to increased care needs included complications, comorbidities, body mass index (BMI), income, history of past illness, simple clinical score (SCS), and activities of daily living (ADL). The predictive performance improved through machine learning, with the random forest model demonstrated the best performance (root mean square error (RMSE): 1148.38; coefficient of determination (R2): 0.74; mean square error (MSE): 1318744.64).

CONCLUSIONS

The variability in nursing workload during hospitalization is influenced primarily by patient self-care capacity, complications, and comorbidities. The random forest algorithm, a machine learning algorithm, effectively handles a wide range of features, such as patient characteristics, complications, comorbidities, and other factors. This algorithm has demonstrated good performance in predicting workload.

IMPLICATIONS FOR NURSING MANAGEMENT

This study introduces a quantitative model designed to evaluate nursing workload throughout the duration of hospitalization. By employing the model, nursing managers can consider multiple factors that impact workload comprehensively, resulting in enhanced comprehension and interpretation of workload variations. Through the application of a random forest algorithm for workload prediction, nursing managers can anticipate and estimate workload in a proactive and precise manner, thereby facilitating more efficient human resource planning.

What would have made work in the COVID-19 ICU less demanding? A qualitative study from 13 Swedish COVID-19 ICUs

BACKGROUND

The COVID-19 pandemic stretched Swedish intensive care unit (ICU) resources to an extent never experienced before, but even before the pandemic staffing was difficult and the number of staffed ICU beds was low. Studies have revealed high levels of COVID-19 ICU staff burn-out and fatigue, and as similar situations with high demands are likely to occur in the future a better understanding of resources that improve staff resilience is important. Using the job-demand resource theory as a framework, we explored ICU professionals' views on demands and resources when working in COVID-19 ICUs with the aim to highlight factors that increased the job resources.

METHODS

Data were collected via a web survey distributed to COVID-19 ICU professionals, including both regular and temporary roles, working in 13 COVID-19 ICU wards in Stockholm and Sörmland counties during the spring 2021. A total of 251 written responses to the question "What would have made work in the COVID-19 ICU less demanding?" were analyzed using thematic analysis. One year later a member-checking focus group interview was conducted to validate and further explore staff experiences.

RESULTS

The main themes were work strategy, fairness and support, continuity, accessible leadership, introduction/information, and crisis preparedness. The analysis of the focus group conducted confirmed the main results and the extreme demands on ICU staff during the initial stages of the pandemic.

CONCLUSION

To increase staff health and performance in a long-term crisis our results suggest; maintaining workplace leadership, scheduling work in advance and, when possible, schedule for recovery.

Comparison of SARS-CoV-2 related in-hospital mortality, ICU admission and mechanical ventilation of 1.4 million patients in Germany and Switzerland, 2019 to 2022

PURPOSE

In the 2020 emergence of SARS-CoV-2, global response lacked unified treatment and surveillance, resulting in diverse impacts due to varied healthcare resources and national guidelines. Germany and Switzerland curbed the virus initially by promptly tracking and testing, bolstered by strong governmental capacity. This study aimed to assess country-specific healthcare disparities and their impact on ICU admission rates, mechanical ventilation, and in-hospital mortality.

METHODS

To enhance healthcare quality using real-world data, the "Initiative of Quality Medicine" (IQM) was established. Pseudonymised routine data from participating hospitals, during 01/01/2019-31/12/2022, was retrospectively analysed, focusing on patients with SARI ± SARS-CoV-2-infection (U07.1). Cohorts were matched based on various factors and multivariable analyses included logistic regression.

RESULTS

1.421.922 cases of SARI ± U07.1 involving 386 German and 41 Swiss hospitals were included. Patients in Germany were older (mean: 69.4 vs. 66.5 years) and had more comorbidities than in Switzerland (p < .001). Patients in Germany were also more likely to be treated on ICU (28% vs. 20%, OR 1.5 95% CI 1.5-1.6, p < .001) and mechanically ventilated (20% vs. 15%, OR 1.4, 95% CI 1.4-1.5, p < .001). The in-hospital mortality was significantly higher in Germany than in Switzerland (21% vs. 12%, OR 2.0, 95% CI 1.9-2.0, p < .001). Matched cohorts showed reduced differences, but Germany still exhibited higher in-hospital mortality. Discrepancies were evident in both pre-pandemic and pandemic analyses, highlighting existing disparities between both countries.

CONCLUSION

IQM data from Swiss and German hospitals reveals country-specific differences in SARI ± U07.1 outcomes, highlighting higher in-hospital mortality in Germany, with uncertain causes suggesting varied treatments and resources.

A prospective longitudinal cohort study of the association between nurses' subjective and objective workload

Critical care nurses have high workloads due to the severity of the disease and the complexity of the treatment and care. Understanding the factors that influence subjective workload as well as the association between subjective and objective workload could lead to new insights to reduce critical care nurses' workload. (1) To describe critical care nurses' subjective and objective workload per shift in a university-affiliated interdisciplinary adult intensive care unit in Switzerland and (2) to explore the association between objective and subjective workload. The study used a prospective longitudinal cohort design. Critical care nurses completed the adapted Questionnaire on the Experience and Evaluation of Work 2.0 (QEEW2.0) to assess the subjective workload after every shift for four weeks (0 = never loaded, 100 = always loaded). The objective workload was assessed with the Therapeutic Intervention Scoring System-28 (TISS-28), Nine Equivalents of Nursing Manpower Use Score (NEMS), Swiss Society for Intensive Care Medicine (SGI)-patients' categories and Patient-to-Nurse Ratio (PNR). Data was analysed using multilevel mixed models. The workload of 60 critical care nurses with a total of 765 shifts were analysed. The critical care nurses experienced a subjective high mental load (66 ± 26), moderate pace and amount of work (30 ± 25) and physical load (33 ± 25), and low emotional-moral load (26 ± 22). The one-time baseline subjective workload values were higher than the day-to-day values. The mean objective shift load using the TISS-28 was 43 ± 16 points, the NEMS 36 ± 14 points, the SGI-category 1.1 ± 0.5 nurses needed per patient and the PNR 1.2 ± 0.4. We found positive associations between day-to-day objective variables with subjective pace and amount of work, with physical and mental load but not with emotional-moral load and performance. Measured objective workload is associated with only certain subjective workload domains. To promote and retain critical care nurses in the profession, nursing management should give a high priority to understanding subjective workload and strategies for reducing it.

Exploring the competencies of Chinese critical care nurses in mobile medical teams based on the onion model: A qualitative study

BACKGROUND

With frequent conflicts, natural disasters, and public health emergencies globally, mobile medical teams (MMTs) are becoming increasingly critical. Importantly, the competency of critical care nurses in MMTs can substantially affect the effectiveness and quality of its rescue efforts. Yet, these nurses' competencies are not well understood.

AIM

This study examined the competencies of critical care nurses in MMTs using the Onion Model.

STUDY DESIGN

A qualitative descriptive method was used to describe the competencies of Chinese MMT critical care nurses. From April to May 2022, a convenience sample of 18 participants (14 critical care nurses and 4 surgeons) from 10 MMTs was recruited for semi-structured interviews. Deductive and inductive coding methods were combined for content analysis.

RESULTS

In total, 29 competencies were identified, which were grouped into four major domains using the Onion Model. From the outer to inner layers, these domains were knowledge and skills, professional abilities, professional quality, and personal traits. Several novel competencies emerged, including field medical equipment operation skills, on-site hazard identification and safety prevention skills, triage knowledge, and field survival skills.

CONCLUSIONS

Using the Onion Model, this study furthers the understanding of the competency of critical care nurses in MMTs, especially by revealing the novel competencies. Further, the results can be used to recruit, evaluate, and train critical care nurses for MMTs.

RELEVANCE TO CLINICAL PRACTICE

Understanding MMT critical care nurses' competencies can help managers plan and provide relevant training and education before deployment, which can improve nurses' performance, and especially reduce the mortalities and disabilities from trauma.

The advancement of critical care nursing as a response to the current demands

The current demand on health services requires that nurses play a key role, by adapting their competencies to different fields and complexity levels. The approach of situations presented by critically ill patients underpins the need for development of specialised competencies in specific areas such as patient safety, prevention and control of healthcare-associated infections, performance of specific techniques and interventions, autonomous medication management or the use of technology, among others. Spain relies on a specialist training programme that is unique worldwide. Training admission is managed through a contract as a "Resident Nurse Intern" (EIR, Enfermera Interna Residente), provided by regional healthcare services. Only 6 specialities have been established and developed, in an uneven manner and with a short provision of places, annually. Given that the specialization in critical care nursing does not exist, nurses usually self-fund their postgraduate training to enhance their opportunities career development. The development of a speciality for critical care nursing is a priority. The models proposed advocate for creating nursing roles that could cover the systemic gaps through the expansion of their competencies and the introduction of procedures that fit nursing into advanced practice, which could be achieved through Advanced Accreditation Diplomas. Simultaneously, it would be convenient to analyse how and why such a dynamic discipline in some countries became stuck in anachronistic models of the Spanish healthcare system. This analysis might contribute to move forward on the development of areas of improvement in terms of service access and quality of care.

Incidence, risk factors and clinical outcome of multidrug-resistant organisms after heart transplantation

BACKGROUND

Transplant recipients commonly harbor multidrug-resistant organisms (MDROs), as a result of frequent hospital admissions and increased exposure to antimicrobials and invasive procedures.

AIM

To investigate the impact of patient demographic and clinical characteristics on MDRO acquisition, as well as the impact of MDRO acquisition on intensive care unit (ICU) and hospital length of stay, and on ICU mortality and 1-year mortality post heart transplantation.

METHODS

This retrospective cohort study analyzed 98 consecutive heart transplant patients over a ten-year period (2013-2022) in a single transplantation center. Data was collected regarding MDROs commonly encountered in critical care.

RESULTS

Among the 98 transplanted patients (70% male), about a third (32%) acquired or already harbored MDROs upon transplantation (MDRO group), while two thirds did not (MDRO-free group). The prevalent MDROs were Acinetobacter baumannii (14%), Pseudomonas aeruginosa (12%) and Klebsiella pneumoniae (11%). Compared to MDRO-free patients, the MDRO group was characterized by higher body mass index (P = 0.002), higher rates of renal failure (P = 0.017), primary graft dysfunction (10% vs 4.5%, P = 0.001), surgical re-exploration (34% vs 14%, P = 0.017), mechanical circulatory support (47% vs 26% P = 0.037) and renal replacement therapy (28% vs 9%, P = 0.014), as well as longer extracorporeal circulation time (median 210 vs 161 min, P = 0.003). The median length of stay was longer in the MDRO group, namely ICU stay was 16 vs 9 d in the MDRO-free group (P = 0.001), and hospital stay was 38 vs 28 d (P = 0.006), while 1-year mortality was higher (28% vs 7.6%, log-rank-χ 2: 7.34).

CONCLUSION

Following heart transplantation, a predominance of Gram-negative MDROs was noted. MDRO acquisition was associated with higher complication rates, prolonged ICU and total hospital stay, and higher post-transplantation mortality.

The impact of nursing workforce skill-mix on patient outcomes in intensive care units in Victoria, Australia

Objective

This article aims to examine the impact of nursing workforce skill-mix (percentage of critical care registered nurses [CCRN]) in the intensive care unit (ICU) during a patient's stay.

Design

Registry linked cohort study of the Australian and New Zealand Intensive Care Society Adult Patient Database and the Critical Health Resources Information System using real-time nursing workforce data.

Settings

Fifteen public and 5 private hospital ICUs in Victoria, Australia.

Participants

There were 16,618 adult patients admitted between 1 December 2021 and 30 September 2022.

Main outcome measures

Primary outcome: in-hospital mortality. Secondary outcomes: in-ICU mortality, development of delirium, pressure injury, duration of stay in-ICU and hospital, after-hours discharge from ICU and readmission to ICU.

Results

In total, 6563 (39.5%) patients were cared for in ICUs with >75% CCRN, 7695 (46.3%) in ICUs with 50-75% CCRN, and 2360 (14.2%) in ICUs with <50% CCRN. In-hospital mortality was 534 (8.1%) vs. 859 (11.2%) vs. 252 (10.7%) respectively. After adjusting for confounders, patients cared for in ICUs with 50-75% CCRN (adjusted OR 1.21 [95% CI 1.02-1.45]) were more likely to die compared to patients in ICUs with >75% CCRN. A similar but non-significant trend was seen in ICUs with <50% CCRN (adjusted OR 1.21 [95% CI 0.94-1.55]), when compared to patients in ICUs with >75% CCRN. In-ICU mortality, delirium, pressure injuries, after-hours discharge and ICU length of stay were lower in ICUs with CCRN>75%.

Conclusion

The nursing skill-mix in ICU impacts outcomes and should be routinely monitored. Health system regulators, hospital administrators and ICU leaders should ensure nursing workforce planning and education align with these findings to maximise patient outcomes.

Inpatient midwifery staffing levels and postpartum readmissions: a retrospective multicentre longitudinal study

BACKGROUND

Preventing readmission to hospital after giving birth is a key priority, as rates have been rising along with associated costs. There are many contributing factors to readmission, and some are thought to be preventable. Nurse and midwife understaffing has been linked to deficits in care quality. This study explores the relationship between staffing levels and readmission rates in maternity settings.

METHODS

We conducted a retrospective longitudinal study using routinely collected individual patient data in three maternity services in England from 2015 to 2020. Data on admissions, discharges and case-mix were extracted from hospital administration systems. Staffing and workload were calculated in Hours Per Patient day per shift in the first two 12-hour shifts of the index (birth) admission. Postpartum readmissions and staffing exposures for all birthing admissions were entered into a hierarchical multivariable logistic regression model to estimate the odds of readmission when staffing was below the mean level for the maternity service.

RESULTS

64 250 maternal admissions resulted in birth and 2903 mothers were readmitted within 30 days of discharge (4.5%). Absolute levels of staffing ranged between 2.3 and 4.1 individuals per midwife in the three services. Below average midwifery staffing was associated with higher rates of postpartum readmissions within 7 days of discharge (adjusted OR (aOR) 1.108, 95% CI 1.003 to 1.223). The effect was smaller and not statistically significant for readmissions within 30 days of discharge (aOR 1.080, 95% CI 0.994 to 1.174). Below average maternity assistant staffing was associated with lower rates of postpartum readmissions (7 days, aOR 0.957, 95% CI 0.867 to 1.057; 30 days aOR 0.965, 95% CI 0.887 to 1.049, both not statistically significant).

CONCLUSION

We found evidence that lower than expected midwifery staffing levels is associated with more postpartum readmissions. The nature of the relationship requires further investigation including examining potential mediating factors and reasons for readmission in maternity populations.

Unfinished nursing care in intensive care units and the mediating role of the association between nurse working environment, and quality of care and nurses' wellbeing

OBJECTIVES

Unfinished care refers to the situation in which nurses are forced to delay or omit necessary nursing care. The objectives was: 1) to measure the prevalence of unfinished nursing care in intensive care units during the COVID-19 pandemic; 2) to examine whether unfinished nursing care has a mediating role in the relationship between nurse working environment and nurse-perceived quality of care and risk of burnout among nurses.

DESIGN

A national cross-sectional survey.

SETTING

Seventy-five intensive care units in Belgium (December 2021 to February 2022).

MAIN OUTCOME MEASURES

The Practice Environment Scale of the Nursing Work Index was used to measure the work environment. The perception of quality and safety of care was evaluated via a Likert-type scale. The risk of burnout was assessed using the Maslach Burnout Inventory scale.

RESULTS

A total of 2,183 nurse responses were included (response rate of 47.8%). Seventy-six percent of nurses reported at least one unfinished nursing care activity during their last shift. The staffing and resource adequacy subdimension of the Practice Environment Scale of the Nursing Work Index had the strongest correlation with unfinished nursing care. An increase in unfinished nursing care led to significantly lower perceived quality and safety of care and an increase in high risk of burnout. Unfinished nursing care appears to be a mediating factor for the association between staffing and resource adequacy and the quality and safety of care perceived by nurses and risk of burnout.

CONCLUSIONS

Unfinished nursing care, which is highly related to staffing and resource adequacy, is associated with increased odds of nurses being at risk of burnout and reporting a lower level of perceived quality of care.

IMPLICATIONS FOR CLINICAL PRACTICE

The monitoring of unfinished nursing care in the intensive care unit is an important early indicator of problems related to adequate staffing levels, the well-being of nurses, and the perceived quality of care.

Measuring the Impact of ICU Strain on Mortality, After-Hours Discharge, Discharge Delay, Interhospital Transfer, and Readmission in Australia With the Activity Index

OBJECTIVES

ICU resource strain leads to adverse patient outcomes. Simple, well-validated measures of ICU strain are lacking. Our objective was to assess whether the "Activity index," an indicator developed during the COVID-19 pandemic, was a valid measure of ICU strain.

DESIGN

Retrospective national registry-based cohort study.

SETTING

One hundred seventy-five public and private hospitals in Australia (June 2020 through March 2022).

SUBJECTS

Two hundred seventy-seven thousand seven hundred thirty-seven adult ICU patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data from the Australian and New Zealand Intensive Care Society Adult Patient Database were matched to the Critical Health Resources Information System. The mean daily Activity index of each ICU (census total of "patients with 1:1 nursing" + "invasive ventilation" + "renal replacement" + "extracorporeal membrane oxygenation" + "active COVID-19," divided by total staffed ICU beds) during the patient's stay in the ICU was calculated. Patients were categorized as being in the ICU during very quiet (Activity index < 0.1), quiet (0.1 to < 0.6), intermediate (0.6 to < 1.1), busy (1.1 to < 1.6), or very busy time-periods (≥ 1.6). The primary outcome was in-hospital mortality. Secondary outcomes included after-hours discharge from the ICU, readmission to the ICU, interhospital transfer to another ICU, and delay in discharge from the ICU. Median Activity index was 0.87 (interquartile range, 0.40-1.24). Nineteen thousand one hundred seventy-seven patients died (6.9%). In-hospital mortality ranged from 2.4% during very quiet to 10.9% during very busy time-periods. After adjusting for confounders, being in an ICU during time-periods with higher Activity indices, was associated with an increased risk of in-hospital mortality (odds ratio [OR], 1.49; 99% CI, 1.38-1.60), after-hours discharge (OR, 1.27; 99% CI, 1.21-1.34), readmission (OR, 1.18; 99% CI, 1.09-1.28), interhospital transfer (OR, 1.92; 99% CI, 1.72-2.15), and less delay in ICU discharge (OR, 0.58; 99% CI, 0.55-0.62): findings consistent with ICU strain.

CONCLUSIONS

The Activity index is a simple and valid measure that identifies ICUs in which increasing strain leads to progressively worse patient outcomes.

Nursing workload and patient-focused outcomes in intensive care: A systematic review

The aim of this systematic review was to examine the association of nursing workload on patient outcomes in intensive care units. The primary outcome measure was patient mortality, with adverse events (AE), the secondary outcome measures. Electronic search of databases including MEDLINE, CINAHL, Cochrane, EMCARE, Scopus, and Web of Science were performed. Studies were excluded if they were in non-ICU settings, pediatric, neonatal populations, or if the abstract/full text was unavailable. Risk of bias was assessed by the ROBINS-I tool. After screening 4129 articles, 32 studies were identified as meeting inclusion criteria. The majority of included studies were assessed as having a moderate risk of bias. The nursing activities score (NAS) was the most frequently used tool to assess nursing workload. Our systematic review identified that higher nursing workload was associated with patient-focused outcomes, including increased mortality and AE in the intensive care setting. The varied approaches of measuring and reporting nursing workload make it difficult to translate the findings of the impact of nursing workload on patient outcomes in intensive care settings.

Six-month post-intensive care outcomes during high and low bed occupancy due to the COVID-19 pandemic: A multicenter prospective cohort study

INTRODUCTION

The COVID-19 pandemic can be seen as a natural experiment to test how bed occupancy affects post-intensive care unit (ICU) patient's functional outcomes. To compare by bed occupancy the frequency of mental, physical, and cognitive impairments in patients admitted to ICU during the COVID-19 pandemic.

METHODS

Prospective cohort of adults mechanically ventilated >48 hours in 19 ICUs from seven Chilean public and private hospitals. Ninety percent of nationwide beds occupied was the cut-off for low versus high bed occupancy. At ICU discharge, 3- and 6-month follow-up, we assessed disability using the World Health Organization Disability Assessment Schedule 2.0. Quality of life, mental, physical, and cognitive outcomes were also evaluated following the core outcome set for acute respiratory failure.

RESULTS

We enrolled 252 participants, 103 (41%) during low and 149 (59%) during high bed occupancy. Patients treated during high occupancy were younger (P50 [P25-P75]: 55 [44-63] vs 61 [51-71]; p<0.001), more likely to be admitted due to COVID-19 (126 [85%] vs 65 [63%]; p<0.001), and have higher education qualification (94 [63%] vs 48 [47%]; p = 0.03). No differences were found in the frequency of at least one mental, physical or cognitive impairment by bed occupancy at ICU discharge (low vs high: 93% vs 91%; p = 0.6), 3-month (74% vs 63%; p = 0.2) and 6-month (57% vs 57%; p = 0.9) follow-up.

CONCLUSIONS

There were no differences in post-ICU outcomes between high and low bed occupancy. Most patients (>90%) had at least one mental, physical or cognitive impairment at ICU discharge, which remained high at 6-month follow-up (57%).

CLINICAL TRIAL REGISTRATION

NCT04979897 (clinicaltrials.gov).

Critical care and pandemic preparedness and response

Critical care was established partially in response to a polio epidemic in the 1950s. In the intervening 70 yr, several epidemics and pandemics have placed critical care and allied services under extreme pressure. Pandemics cause wholesale changes to accepted standards of practice, require reallocation and retargeting of resources and goals of care. In addition to clinical acumen, mounting an effective critical care response to a pandemic requires local, national, and international coordination in a diverse array of fields from research collaboration and governance to organisation of critical care networks and applied biomedical ethics in the eventuality of triage situations. This review provides an introduction to an array of topics that pertain to different states of pandemic acuity: interpandemic preparedness, alert, surge activity, recovery and relapse through the literature and experience of recent pandemics including COVID-19, H1N1, Ebola, and SARS.

Info-NAS: A Computer Program for the Calculation of Intensive Care Unit Nurse Workload

The purpose of this study was to design an algorithm that allows automatic calculation of nursing workload in intensive care units, based on the Nursing Activities Score scale, through a computer program. Three methodological steps were used: (1) Delphi method (group of experts); (2) identification of the correspondence: Nursing Activities Score items-variables in the EHR, namely, standardized terminology, laboratory values, and prescriptions; and (3) weighting of variables independently by a group of experts. Finally, the algorithm of the computer program was tested. The results showed an algorithm that calculates the nursing workload in an ICU. The calculation is objective and automatic through the EHRs. This study shows the feasibility of the algorithm as a rapid and objective strategy to quantify adequate nurse staffing in intensive care units. Moreover, it provides nurses with a practical resource for the correct completion of records and is thus an incentive to maintain or improve their quality.

Factors related to COVID-19 mortality among three Swedish intensive care units-A retrospective study

BACKGROUND

Mortality due to acute hypoxemic respiratory failure (AHRF) in patients with coronavirus disease-19 (COVID-19) differs across units, regions, and countries. These variations may be attributed to several factors, including comorbidities, acute physiological derangement, disease severity, treatment, ethnicity, healthcare system strain, and socioeconomic status. This study aimed to explore the features of patient characteristics, clinical management, and staffing that may be related to mortality among three intensive care units (ICUs) within the same hospital system in South Sweden.

METHODS

We retrospectively analyzed ICU patients with COVID-19 and AHRF in Region Jönköping County, Sweden. The primary outcome was the 90-day mortality rate. We used univariate and multivariable logistic regression analyses to investigate the relationship of predictors with outcomes.

RESULTS

Between March 15, 2020, and May 31, 2021, 331 patients with AHRF and COVID-19 were admitted to the three ICUs. There were differences in disease severity, treatments, process-related factors, and socioeconomic factors between the units. These factors were related to 90-day mortality. After multivariable adjustment, age, severity of acute respiratory distress syndrome, and the number of nurses per ICU-bed independently predicted 90-day mortality.

CONCLUSION

Age, disease severity, and nurse staffing, but not treatment or socioeconomic status, were independently associated with 90-day mortality among critically ill patients with AHRF due to COVID-19. We also identified variations in care related processes, which may be a modifiable risk factor and warrants future investigation.

The Impact of Nursing Skill-mix on Adverse Events in Intensive Care: A Single Centre Cohort Study

BACKGROUND

The highly complex and technological environment of critical care manages the most critically unwell patients in the hospital system, as such there is a need for a highly trained nursing workforce. Intensive care is considered a high-risk area for errors and adverse events (AE) due to the severity of illness and number of procedures performed.

OBJECTIVE

To investigate if the percentage of Critical Care Registered Nurses (CCRN) within an Intensive Care Unit (ICU) is associated with an increased risk of patients experiencing an AE.

DESIGN & SETTING

We conducted a retrospective cohort study of patients admitted between January 2016 and December 2020 to a tertiary ICU in Australia. Descriptive statistics and multivariable logistic regression were used to investigate the relationship between the proportion of CCRNs each month and the occurrence of an AE defined as any one of a medication error, fall, pressure injury or unplanned removal of a central venous catheter or endotracheal tube per patient.

RESULTS

A total of 13,560 patients were included in the study, with 854 (6.3%) experiencing one AE. Patients with an AE were associated with higher illness severity and frailty scores. They were more commonly admitted after medical emergency team response calls and were less commonly elective ICU admissions. Those with an AE had longer ICU and in-hospital length of stay, and higher ICU and in-hospital mortality, on average. After adjusting for ICU LOS and acute severity of illness, being admitted during a month of higher critical care nursing skill-mix was associated with a statistically significant lower odds of having a subsequent AE (OR 0.966 [95% CI: 0.944-0.988], p 0.003).

CONCLUSION

An increasing percentage of CCRNs is independently associated with a lower risk-adjusted likelihood of an AE. Increasing the skill-mix of the ICU nursing staff may reduce the occurrence of AEs and lead to improved patient outcomes.

The association between multi-disciplinary staffing levels and mortality in acute hospitals: a systematic review

OBJECTIVES

Health systems worldwide are faced with the challenge of adequately staffing their hospital services. Much of the current research and subsequent policy has been focusing on nurse staffing and minimum ratios to ensure quality and safety of patient care. Nonetheless, nurses are not the only profession who interact with patients, and, therefore, not the only professional group who has the potential to influence the outcomes of patients while in hospital. We aimed to synthesise the evidence on the relationship between multi-disciplinary staffing levels in hospital including nursing, medical and allied health professionals and the risk of death.

METHODS

Systematic review. We searched Embase, Medline, CINAHL, and the Cochrane Library for quantitative or mixed methods studies with a quantitative component exploring the association between multi-disciplinary hospital staffing levels and mortality.

RESULTS

We included 12 studies. Hospitals with more physicians and registered nurses had lower mortality rates. Higher levels of nursing assistants were associated with higher patient mortality. Only two studies included other health professionals, providing scant evidence about their effect.

CONCLUSIONS

Pathways for allied health professionals such as physiotherapists, occupational therapists, dietitians, pharmacists, to impact safety and other patient outcomes are plausible and should be explored in future studies.

The Relationship of Nurse and Physician Staffing in Intensive Care Units with Patient Outcomes in Postoperative Patients on Ventilators: An Analysis Using Korean National Health Insurance Data

This study examined the associations of nurse and physician staffing in intensive care units (ICUs) with hospital-acquired pneumonia (HAP) incidence and in-hospital mortality in postoperative patients on ventilators. National Health Insurance claims data and death statistics were used to investigate the nurse staffing level and the presence or absence of a dedicated resident and specialist in each ICU. The participants were patients aged 20-85 who underwent any of 13 surgical procedures and were placed on a ventilator in the ICU after the procedure. Of 11,693 patients, 307 (2.6%) experienced HAP and 1280 (10.9%) died during hospitalization. Compared to hospitals with lower nurse-to-patient ratios, patients in hospitals with higher ratios had statistically significantly higher risks of HAP and in-hospital mortality. The presence of a dedicated resident in the ICU did not statistically significantly affect HAP incidence or in-hospital mortality. The presence of an ICU specialist was statistically significantly associated with in-hospital mortality but not HAP incidence. Our findings suggest that a higher level of nursing staff in the ICU is inversely associated with HAP incidence. The legal standards for nurse staffing in the ICU should be strengthened in order to improve the quality of care and patient safety.

Nurse staffing levels in critical care: The impact of patient characteristics

BACKGROUND

Intensive care is one of the most resource-intensive forms of care because seriously ill patients are cared for in units with high staffing levels. Studies show that the number of registered nurses (RNs) per patient and nurse education level affects patient outcome. However, there is a lack of studies that consider how nurses/patient ratio with an advanced educational level of specialized nurses in intensive care, affect the intensive care performed in different patient populations.

AIM

To investigate if differences in patient characteristics and nurse-patient ratio have an impact on the quality of care.

STUDY DESIGN

This is a retrospective observational study with a review of all patients >15 years receiving care at two general intensive care units with different nurse/patient ratio (unit A, 1:1 nurse/patient ratio and unit B, 0.5:1 nurse/patient ratio).

RESULTS

There was no significant difference in the initial severity of illness between the units. However, younger patients, male patients and patients requiring surgery entailed a higher workload and a longer intensive care unit (ICU) stay despite a 1:1 critical care nurse/patient ratio. A small difference, but not significant, with more unplanned re-intubations occurred at unit A compared with unit B.

CONCLUSION

The differences in the nurse/patient ratio did not reflect a difference in the severity of illness among admitted patients but might be explained by patient characteristics with different needs.

RELEVANCE TO CLINICAL PRACTICE

Health care managers should consider not only the number of nurses but also their educational level, specific competencies and skills mix and nursing-sensitive measures to provide high-quality ICU care in settings with different patient characteristics. Nursing-sensitive patient outcomes should be considered in relation to nurse/patient ratio, as important to measure to ensure a high quality of patient care in the ICU.

Shift work organization on nurse injuries: A scoping review

BACKGROUND

Extended work hours and shift work can result in mistimed sleep, excessive sleepiness, and fatigue, which affects concentration and cognition. Impaired concentration and cognition negatively affect employee safety.

OBJECTIVE

To examine the evidence of the impact of shift work organization, specifically work hours and scheduling, on nurse injuries including needlestick and sharps injuries, drowsy driving and motor vehicle crashes, and work-related accidents causing a near miss or actual injury to the nurse.

METHODS

A scoping review was conducted using search results from five bibliographic databases.

RESULTS

Through database searching, 7788 articles were identified. During the title and abstract screening, 5475 articles were excluded. Full text screening eliminated 1971 articles. During the data extraction phase, 206 articles were excluded leaving 34 articles from 14 countries in the scoping review. The results of the review suggest a strong association in nurses between long work hours and overtime and an increased risk for needlestick and sharps injuries, drowsy driving and motor vehicle crashes, and other work-related accidents. Rotating shifts increase the risk for needlestick and sharps injuries and other work-related accidents while night and rotating shifts increase the risk for drowsy driving and motor vehicle crashes.

CONCLUSIONS

Proper management of work hours and scheduling is essential to maximize recovery time and reduce or prevent nurse injuries. Nurse leaders, administrators, and managers, have a responsibility to create a culture of safety. This begins with safe scheduling practices, closely monitoring for near miss and actual nurse injuries, and implementing evidence-based practice strategies to reduce these occurrences.

Nursing workforce deployment and intensive care unit strain during the COVID-19 pandemic in Victoria, Australia

BACKGROUND

The COVID-19 pandemic demanded intensive care units (ICUs) globally to expand to meet increasing patient numbers requiring critical care. Critical care nurses were a finite resource in this challenge to meet growing patient numbers, necessitating redeployment of nursing staff to work in ICUs.

OBJECTIVE

Our aim was to describe the extent and manner by which the increased demand for ICU care during the COVID-19 pandemic was met by ICU nursing workforce expansion in the late 2021 and early 2022 in Victoria, Australia.

METHODS

This is a retrospective cohort study of Victorian ICUs who contributed nursing data to the Critical Health Information System from 1 December 2021 to 11 April 2022. Bedside nursing workforce data, in categories as defined by Safer Care Victoria's pandemic response guidelines, were analysed. The primary outcome was 'insufficient ICU skill mix'-whenever a site had more patients needing 1:1 critical care nursing care than the mean daily number of experienced critical care nursing staff.

RESULTS

Overall, data from 24 of the 47 Victorian ICUs were eligible for analysis. Insufficient ICU skill mix occurred on 10.3% (280/2725) days at 66.7% (16/24) of ICUs, most commonly during the peak phase from December to mid-February. The insufficient ICU skill mix was more likely to occur when there were more additional ICU beds open over the 'business-as-usual' number. Counterfactual analysis suggested that had there been no redeployment of staff to the ICU, reduced nursing ratios, with inability to provide 1:1 care, would have occurred on 15.2% (415/2725) days at 91.7% (22/24) ICUs.

CONCLUSION

The redeployment of nurses into the ICU was necessary. However, despite this, at times, some ICUs had insufficient staff to cope with the number and acuity of patients. Further research is needed to examine the impact of ICU nursing models of care on patient outcomes and on nurse outcomes.

Effects of technology-based educational tools on nursing learning outcomes in intensive care units: a systematic review and meta-analysis

BACKGROUND

Nurses working in the Intensive Care Unit (ICU), due to the sensitivity and difficulty of tasks, need continuous and scientific training to be able to offer the best performance in difficult situations and use their knowledge in the best way. Also, nursing students spend internships in ICUs and receive special training in practice in the actual center. Educational tools based on new technologies can potentially improve the educational outcomes of nursing in ICUs.

OBJECTIVES

 The present study aims to review and evaluate the effect of using technology-based educational tools for training critical care nurses and nursing students.

METHODS

 A comprehensive search was conducted to identify peer-reviewed English language articles in Embase, Medline (through PubMed), Scopus, and ISI web of science published from 2010 to Feb 18, 2022. The studies that examined the effectiveness of technology-based educational interventions with control groups were included. The risk of bias in each study was assessed using the Cochrane Collaboration's tool. Also, we used Standard Mean Difference (SMD) to estimate the effect of technology-based educational tools on learning outcomes. All meta-analyses were performed with a random effects model in Stata Ver.16.

RESULTS

 Altogether, ten studies were eligible for the quality assessment and systematic review, while one study that had not reported the pre-intervention analysis was excluded from the meta-analysis. Nine studies were considered to have a low RoB regarding reporting ways, and one of them showed a high risk. Performance and selection bias caused a high risk in six and five of the studies, respectively. In the meta-analysis, improvement in knowledge (SMD = 0.91), skills (SMD = 0.52), and self-confidence (SMD = 0.96) was noticed by applying technology-based educational tools.

CONCLUSION

It can be offered that if the learning method based on the new technologies tested is more effective than conventional teaching methods, they are likely to improve the learning outcome significantly. The new-developed tools also have great potential in improving health care functions among nurses or nursing students as well as enhancing the quality of life and patient satisfaction.

Fundamental drivers of nurses' experiences of ICU surging during the coronavirus disease 2019 (COVID-19) pandemic

PURPOSE OF REVIEW

Nurses working in intensive care units have been heavily impacted by the coronavirus disease 2019 (COVID-19) pandemic. This review summarizes the current state of the evidence regarding intensive care nurses experience of the pandemic.

RECENT FINDINGS

The pandemic has had an impact on: nursing workload, the organization of nurse staffing, experiences of staff redeployed into ICU, nurses' perceptions of the safety and quality of patient care, and staff health. In the few comparative studies, mental health was worse for nurses than other healthcare workers in intensive care. Despite some of this evidence being published early in the pandemic, no studies were found to evaluate interventions to improve nurses' experiences.

SUMMARY IMPLICATIONS FOR PRACTICE OR RESEARCH

Many of the adverse impacts of the pandemic are interdependent; for example, reducing nurses' workload is likely to have benefits for mental health indicators.Adverse mental health outcomes are likely to have an impact on future recruitment and retention for intensive care nursing.More studies are needed to understand the longer term impact of the pandemic on intensive care nurses.

The Use of Electronic Health Record Metadata to Identify Nurse-Patient Assignments in the Intensive Care Unit: Algorithm Development and Validation

Background

Nursing care is a critical determinant of patient outcomes in the intensive care unit (ICU). Most studies of nursing care have focused on nursing characteristics aggregated across the ICU (eg, unit-wide nurse-to-patient ratios, education, and working environment). In contrast, relatively little work has focused on the influence of individual nurses and their characteristics on patient outcomes. Such research could provide granular information needed to create evidence-based nurse assignments, where a nurse’s unique skills are matched to each patient’s needs. To date, research in this area is hindered by an inability to link individual nurses to specific patients retrospectively and at scale.

Objective

This study aimed to determine the feasibility of using nurse metadata from the electronic health record (EHR) to retrospectively determine nurse-patient assignments in the ICU.

Methods

We used EHR data from 38 ICUs in 18 hospitals from 2018 to 2020. We abstracted data on the time and frequency of nurse charting of clinical assessments and medication administration; we then used those data to iteratively develop a deterministic algorithm to identify a single ICU nurse for each patient shift. We examined the accuracy and precision of the algorithm by performing manual chart review on a randomly selected subset of patient shifts.

Results

The analytic data set contained 5,479,034 unique nurse-patient charting times; 748,771 patient shifts; 87,466 hospitalizations; 70,002 patients; and 8,134 individual nurses. The final algorithm identified a single nurse for 97.3% (728,533/748,771) of patient shifts. In the remaining 2.7% (20,238/748,771) of patient shifts, the algorithm either identified multiple nurses (4,755/748,771, 0.6%), no nurse (14,689/748,771, 2%), or the same nurse as the prior shift (794/748,771, 0.1%). In 200 patient shifts selected for chart review, the algorithm had a 93% accuracy (ie, correctly identifying the primary nurse or correctly identifying that there was no primary nurse) and a 94.4% precision (ie, correctly identifying the primary nurse when a primary nurse was identified). Misclassification was most frequently due to patient transitions in care location, such as ICU transfers, discharges, and admissions.

Conclusions

Metadata from the EHR can accurately identify individual nurse-patient assignments in the ICU. This information enables novel studies of ICU nurse staffing at the individual nurse-patient level, which may provide further insights into how nurse staffing can be leveraged to improve patient outcomes.

Association between nursing cost and patient outcomes in intensive care units: A retrospective cohort study of Belgian hospitals

INTRODUCTION

Hospitals with better nursing resources report more favourable patient outcomes with almost no difference in cost as compared to those with worse nursing resources. The aim of this study was to assess the association between nursing cost per intensive care unit bed and patient outcomes (mortality, readmission, and length of stay).

METHODOLOGY

This was a retrospective cohort study using data collected from the intensive care units of 17 Belgian hospitals from January 01 to December 31, 2018. Hospitals were dichotomized using median annual nursing cost per bed. A total of 18,235 intensive care unit stays were included in the study with 5,664 stays in the low-cost nursing group and 12,571 in the high-cost nursing group.

RESULTS

The rate of high length of stay outliers in the intensive care unit was significantly lower in the high-cost nursing group (9.2% vs 14.4%) compared to the low-cost nursing group. Intensive care unit readmission was not significantly different in the two groups. Mortality was lower in the high-cost nursing group for intensive care unit (9.9% vs 11.3%) and hospital (13.1% vs 14.6%) mortality. The nursing cost per intensive care bed was different in the two groups, with a median [IQR] cost of 159,387€ [140,307-166,690] for the low-cost nursing group and 214,032€ [198,094-230,058] for the high-cost group. In multivariate analysis, intensive care unit mortality (OR = 0.80, 95% CI: 0.69-0.92, p < 0.0001), in-hospital mortality (OR = 0.82, 95% CI: 0.72-0.93, p < 0.0001), and high length of stay outliers (OR = 0.48, 95% CI: 0.42-0.55, p < 0.0001) were lower in the high-cost nursing group. However, there was no significant effect on intensive care readmission between the two groups (OR = 1.24, 95% CI: 0.97-1.51, p > 0.05).

CONCLUSIONS

This study found that higher-cost nursing per bed was associated with significantly lower intensive care unit and in-hospital mortality rates, as well as fewer high length of stay outliers, but had no significant effect on readmission to the intensive care unit. .

The organisation of nurse staffing in intensive care units: a qualitative study

AIMS

To examine the organisation of the nursing workforce in intensive care units and identify factors that influence how the workforce operates.

BACKGROUND

Pre-pandemic UK survey data show that up to 60% of intensive care units did not meet locally agreed staffing numbers and 40% of ICUs were closing beds at least once a week because of workforce shortages, specifically nursing. Nurse staffing in intensive care is based on the assumption that sicker patients need more nursing resource than those recovering from critical illness. These standards are based on historical working, and expert professional consensus, deemed the weakest form of evidence.

METHODS

Focus groups with intensive care health care professionals (n= 52 participants) and individual interviews with critical care network leads and policy leads (n= 14 participants) in England between December 2019 and July 2020. Data were analysed using framework analysis.

FINDINGS

Three themes were identified: the constraining or enabling nature of intensive care and hospital structures; whole team processes to mitigate nurse staffing shortfalls; and the impact of nurse staffing on patient, staff and intensive care flow outcomes. Staff made decisions about staffing throughout a shift and were influenced by a combination of factors illuminated in the three themes.

CONCLUSIONS

Whilst nurse: patient ratios were clearly used to set the nursing establishment, it was clear that rostering and allocation/re-allocation during a shift took into account many other factors, such as patient and family nursing needs, staff wellbeing, intensive care layout and the experience, and availability, of other members of the multi-professional team. This has important implications for future planning for intensive care nurse staffing and highlights important factors to be accounted for in future research studies.

IMPLICATIONS FOR NURSING MANAGEMENT

In order to safeguard patient and staff safety, factors such as the ICU layout need to be considered in staffing decisions and the local business case for nurse staffing needs to reflect these factors. Patient safety in intensive care may not be best served by a blanket 'ratio' approach to nurse staffing, intended to apply uniformly across health services.

[Dealing with coercion in intensive care medicine : Recommendations from the Ethics Section of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) in collaboration with the Ethics Section of the German Society for Internal Intensive Care and Emergency Medicine (DGIIN)]

The treatment situation in intensive care is characterised by a specific asymmetry in the relationship between patients and the team: Patients are particularly dependent on their environment and often show impaired consciousness and capacity to consent. This facilitates the use of coercion or enables and/or provokes it. The aim of this recommendation is to show ways to recognise patients with their wishes and needs and to integrate them into treatment concepts in the intensive care unit in order to reduce and avoid coercion whenever possible. The recommendation shows the variety of possible forms of coercion and discusses the moral standards to be considered in the ethical weighing process as well as legal conditions for justifying its use. It becomes obvious that treatment measures which may involve the use of coercion always require a careful and self-critical review of the measures in relation to the indication and the therapeutic goal. The recommendation's intention therefore is not to disapprove the use of coercion by interprofessional teams. Instead, it aims to contribute to a sensitive perception of coercion and to a critical and caring approach to formal and especially informal (indirect) coercion.

COVID-19 pandemic: the impact on Canada’s intensive care units

The COVID-19 pandemic has exposed the precarious demand-capacity balance in Canadian hospitals, including critical care where there is an urgent need for trained health care professionals to dramatically increase ICU capacity.

The impact of the pandemic on ICUs varied significantly across the country with provinces that implemented public health measures later and relaxed them sooner being impacted more severely. Pediatric ICUs routinely admitted adult patients. Non-ICU areas were converted to ICUs and staff were redeployed from other essential service areas. Faced with a lack of critical care capacity, triage plans for ICU admission were developed and nearly implemented in some provinces.

Twenty eight percent of patients in Canadian ICUs who required mechanical ventilation died. Surviving patients have required prolonged ICU admission, hospitalization and extensive ongoing rehabilitation. Family members of patients were not permitted to visit, resulting in additional psychological stresses to patients, families, and healthcare teams. ICU professionals also experienced extreme psychological stresses from caring for such large numbers of critically ill patients, often in sub-standard conditions. This resulted in large numbers of health workers leaving their professions.

This pandemic is not yet over, and it is likely that new pandemics will follow. A review and recommendations for the future are provided.

How COVID-19 has affected staffing models in intensive care: A qualitative study examining alternative staffing models (SEISMIC)

AIMS

To understand how COVID-19 affected nurse staffing in intensive care units (ICUs) in England, and to identify factors that influenced, and were influenced by, pandemic staffing models.

DESIGN

Exploratory qualitative study.

METHODS

Semi-structured, online interviews conducted July-September 2020 with regional critical care leaders including policy leads (n = 4) and directors/lead nurses (n = 10) across critical care networks in England.

FINDINGS

The six themes emerging from the framework analysis illustrate how the pre-pandemic ICU culture influenced ICU staffing models during the pandemic. Changes in staffing impacted on the workforce and the care delivered, whilst it was necessary to learn from, and adjust to, a rapidly changing situation. Variation across and between networks necessitated variation in responses. The overwhelming outcome was that the pandemic has challenged the central tenets of ICU nurse staffing.

CONCLUSIONS

Pandemic nurse staffing models resulted in changes to ICU skill-mix and staffing numbers. Factors such as the impact of nurse staffing on care practices and on the workforce need to be taken into account when developing and testing future nurse staffing models for ICU. The extent to which ICUs will return to former staffing models is not yet known but there seems to be an appetite for change.

IMPACT

In common with many countries, nurse staffing in English ICUs was adapted to address surge requirements during the COVID-19 pandemic. Findings highlight the challenge COVID-19 presented to pre-pandemic ICU nurse staffing guidelines, the impact on patient and staff well-being and the potential legacy for future staffing models. Study findings have implications for ICU nurse managers, researchers and policy makers: nurse staffing models need to be adaptable to the local context of care and future research should investigate the impact of different models on patients, staff and health service outcomes.