Nurses' 12-hour shifts and missed or delayed vital signs observations on hospital wards: retrospective observational study

Safer and more efficient vital signs monitoring protocols to identify the deteriorating patients in the general hospital ward: an observational study

Background

The frequency at which patients should have their vital signs (e.g. blood pressure, pulse, oxygen saturation) measured on hospital wards is currently unknown. Current National Health Service monitoring protocols are based on expert opinion but supported by little empirical evidence. The challenge is finding the balance between insufficient monitoring (risking missing early signs of deterioration and delays in treatment) and over-observation of stable patients (wasting resources needed in other aspects of care).

Objective

Provide an evidence-based approach to creating monitoring protocols based on a patient's risk of deterioration and link these to nursing workload and economic impact.

Design

Our study consisted of two parts: (1) an observational study of nursing staff to ascertain the time to perform vital sign observations; and (2) a retrospective study of historic data on patient admissions exploring the relationships between National Early Warning Score and risk of outcome over time. These were underpinned by opinions and experiences from stakeholders.

Setting and participants

Observational study: observed nursing staff on 16 randomly selected adult general wards at four acute National Health Service hospitals. Retrospective study: extracted, linked and analysed routinely collected data from two large National Health Service acute trusts; data from over 400,000 patient admissions and 9,000,000 vital sign observations.

Results

Observational study found a variety of practices, with two hospitals having registered nurses take the majority of vital sign observations and two favouring healthcare assistants or student nurses. However, whoever took the observations spent roughly the same length of time. The average was 5:01 minutes per observation over a 'round', including time to locate and prepare the equipment and travel to the patient area. Retrospective study created survival models predicting the risk of outcomes over time since the patient was last observed. For low-risk patients, there was little difference in risk between 4 hours and 24 hours post observation.

Conclusions

We explored several different scenarios with our stakeholders (clinicians and patients), based on how 'risk' could be managed in different ways. Vital sign observations are often done more frequently than necessary from a bald assessment of the patient's risk, and we show that a maximum threshold of risk could theoretically be achieved with less resource. Existing resources could therefore be redeployed within a changed protocol to achieve better outcomes for some patients without compromising the safety of the rest. Our work supports the approach of the current monitoring protocol, whereby patients' National Early Warning Score 2 guides observation frequency. Existing practice is to observe higher-risk patients more frequently and our findings have shown that this is objectively justified. It is worth noting that important nurse-patient interactions take place during vital sign monitoring and should not be eliminated under new monitoring processes. Our study contributes to the existing evidence on how vital sign observations should be scheduled. However, ultimately, it is for the relevant professionals to decide how our work should be used.

Study registration

This study is registered as ISRCTN10863045.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/03) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 6. See the NIHR Funding and Awards website for further award information.

General ward nurses detection and response to clinical deterioration in three hospitals at the Kenyan coast: a convergent parallel mixed methods study

BACKGROUND

In low and middle-income countries like Kenya, critical care facilities are limited, meaning acutely ill patients are managed in the general wards. Nurses in these wards are expected to detect and respond to patient deterioration to prevent cardiac arrest or death. This study examined nurses' vital signs documentation practices during clinical deterioration and explored factors influencing their ability to detect and respond to deterioration.

METHODS

This convergent parallel mixed methods study was conducted in the general medical and surgical wards of three hospitals in Kenya's coastal region. Quantitative data on the extent to which the nurses monitored and documented the vital signs 24 h before a cardiac arrest (death) occurred was retrieved from patients' medical records. In-depth, semi-structured interviews were conducted with twenty-four purposefully drawn registered nurses working in the three hospitals' adult medical and surgical wards.

RESULTS

This study reviewed 405 patient records and found most of the documentation of the vital signs was done in the nursing notes and not the vital signs observation chart. During the 24 h prior to death, respiratory rate was documented the least in only 1.2% of the records. Only a very small percentage of patients had any vital event documented for all six-time points, i.e. four hourly. Thematic analysis of the interview data identified five broad themes related to detecting and responding promptly to deterioration. These were insufficient monitoring of vital signs linked to limited availability of equipment and supplies, staffing conditions and workload, lack of training and guidelines, and communication and teamwork constraints among healthcare workers.

CONCLUSION

The study showed that nurses did not consistently monitor and record vital signs in the general wards. They also worked in suboptimal ward environments that do not support their ability to promptly detect and respond to clinical deterioration. The findings illustrate the importance of implementation of standardised systems for patient assessment and alert mechanisms for deterioration response. Furthermore, creating a supportive work environment is imperative in empowering nurses to identify and respond to patient deterioration. Addressing these issues is not only beneficial for the nurses but, more importantly, for the well-being of the patients they serve.

Influence of the work environment of nurses on the 30-day mortality of patients hospitalized in Polish hospitals. cross-sectional studies

BACKGROUND

An optimal work environment for nurses is characterized primarily by appropriate staffing, good team relations, and support from the management staff. These factors are consistently associated with a positive assessment of patient safety by a hospital's employees and a reduction in hospital mortality rates.

AIM

To understand the relationships between the work environment as perceived by nurses on the 30-day mortality of patients treated in Polish hospitals.

BACKGROUND

An optimal work environment for nurses is characterized primarily by appropriate staffing, good team relations, and support from the management staff. These factors are consistently associated with a positive assessment of patient safety by a hospital's employees and a reduction in hospital mortality rates.

MATERIAL AND METHODS

The analysis used discharge data from 108,284 patients hospitalized in internal medicine and surgery departments in 21 hospitals (with 24/7 operations) in Poland. Administrative data included coded data to estimate 30-day mortality. A Nurses' satisfaction questionnaire, including the PES-NWI scale and the SAQ questionnaire, was used to assess the work environment of nurses (n = 1,929). Correlations between variables were assessed using the Pearson coefficient. The analysis used a Poisson regression model, which belongs to the class of generalized linear models.

RESULTS

A lower 30-day mortality rate amongst patients was found among those treated in hospitals where the personnel feel that they may question the decisions or actions of their superiors regarding the care provided (r = - 0.50); nurses are informed about changes introduced on the basis of reports about negligence and mistakes (r = - 0.50); the ward nurse is a good manager (r = - 0.41); nurses receive timely information from the head of the department that may have an impact on their work (r = - 0.41).

CONCLUSIONS

Factors related to care during hospital stay such as the organization of care at the ward level, analysis of care errors, the number of staff providing direct patient care, informing nurses about mistakes without punishment, and the possibility of nurses challenging the decisions or actions of superiors, which concerns care providing, affect the 30-day mortality of patients after the end of hospitalization in Polish hospitals.

Examining Nurses' Perception of Shift Work and Evaluating Supportive Interventions

BACKGROUND

Health care requires a delicate equilibrium of nurse health safety and patient safety outcomes. Shift work can disrupt this balance, resulting in poor outcomes for staff and patients.

PROBLEM

Limited evidence exists on nurses' perceptions of shift work, fatigue countermeasures use, and interest in risk-mitigating interventions.

METHODS

An online survey of nurses was conducted. Survey questions assessed perceptions of shift work, use of fatigue countermeasures, and potential interventions.

RESULTS

The participants perceived multiple differences between day and night shifts when asked about their ability to complete both work- and life-oriented tasks. Use of fatigue countermeasures was more common while working night shift. Potential interventions included the use of blackout curtains, an on-site exercise facility, consulting a nutritionist, and block scheduling.

CONCLUSIONS

Health care leaders should consider nurses' perceptions and interests when incorporating initiatives to mitigate the negative effects of shift work.

Pediatric vital signs monitoring in hospital wards: Recognition systems and factors influencing nurses' attitudes and practices

AIMS

To describe: 1) systems in place for recognition and response to deteriorating children in Italy, 2) attitudes and practices of registered nurses (RN) towards vital signs (VS) monitoring in pediatric wards, 3) the associations of nurses attitudes and pratices with nurses' and organizational characteristics.

DESIGN AND METHODS

A multicentre cross-sectional correlational study. Data were collected between January-May 2020 using: an adapted version of the 'Survey on Recognition and Response Systems in Australia', and the 'Ped-V Scale'. Descriptive and adjusted linear regression analysis was performed, accounting for clustering.

RESULTS

Ten Italian hospitals participated, 432 RNs responded to the Ped-V scale (response rate = 52%). Five (50%) hospitals had a VS policy in place, three hospitals (30%) had a Pediatric Early Warning System (PEWS), almost all hospitals had a system in place to respond to deteriorating children. Following multivariate regression analysis, having a PEWS was significantly associated with Ped-V scale 'Workload', 'Clinical competence', 'Standardization' dimensions; gender was associated with 'key indicators' and pediatric surgical ward with 'Clinical competence'.

CONCLUSIONS

The use of VS policies and PEWS was not consistent across hospitals caring for children in Italy. Nurses' attitudes and practices (i.e., perception of workload, and clinical competence) were significantly lower in hospitals with increased complexity of care/PEWS. Gender was significantly associated with knowledge scores.

PRACTICE IMPLICATIONS

System strategies to improve nurses' attitudes and practices towards VS monitoring and education are warranted to support effective behaviors towards VS monitoring, their interpretation, and appropriate communication to activate the efferent limb of the rapid response system.

ChroniSense National Early Warning Score Study: Comparison Study of a Wearable Wrist Device to Measure Vital Signs in Patients Who Are Hospitalized

BACKGROUND

Wearable devices could be used to continuously monitor vital signs in patients who are hospitalized, but they require validation.

OBJECTIVE

This study aimed to evaluate the clinical validity of the prototype of a semiautomated wearable wrist device (ChroniSense Polso) to measure vital signs and provide National Early Warning Scores (NEWSs).

METHODS

Vital signs and NEWSs measured using the wearable device were compared with standard, nurse-lead manual measurements. We enrolled adult patients (aged ≥18 years) who required vital sign measurements at least every 6 hours in a UK teaching district general hospital. Wearable device measurements were not used for clinical decision-making. The primary outcome was the agreement on the individual National Early Warning parameter scores and vital sign measurements: respiratory rate, oxygen saturation, body temperature, systolic blood pressure, and heart rate. Secondary outcomes were the agreement on the total NEWS, incidence of adverse events, and user acceptance. To compare the wearable device measurements with the standard measurements, we analyzed vital sign measurements by limits of agreement (Bland-Altman analysis) and conducted κ agreement analyses for NEWSs. A user experience survey was conducted with questions about comfort of the wrist device, safety, preference, and use.

RESULTS

We included 132 participants in the study, with a mean age of 62 (SD 15.81) years; most of them were men (102/132, 77.3%). The highest weighted κ values were found for heart rate (0.69, 95% CI 0.57-0.81 for all 385 measurements) and systolic blood pressure (0.39, 95% CI 0.30-0.47 for all 339 measurements). Weighted κ values were low for respiration rate (0.03, 95% CI -0.001 to 0.05 for all 445 measurements), temperature (0, 95% CI 0-0 for all 231 measurements), and oxygen saturation (-0.11, 95% CI -0.20 to -0.02 for all 187 measurements). Weighted κ using Cicchetti-Allison weights showed κ of 0.20 (95% CI 0.03-0.38) when using all 56 total NEWSs. The user acceptance survey found that approximately half (45/91, 49%) of the participants found it comfortable to wear the device and liked its appearance. Most (85/92, 92%) of them said that they would wear the device during their next hospital visit, and many (74/92, 80%) said that they would recommend it to others.

CONCLUSIONS

This study shows the promising use of a prototype wearable device to measure vital signs in a hospital setting. Agreement between the standard measurements and wearable device measurements was acceptable for systolic blood pressure and heart rate, but needed to be improved for respiration rate, temperature, and oxygen saturation. Future studies need to improve the clinical validity of this wearable device. Large studies are required to assess clinical outcomes and cost-effectiveness of wearable devices for vital sign measurement.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2018-028219.

The effect of full-time culture on quality and safety of care – a literature review

Purpose

The purpose of this study is to increase knowledge and understanding of the relationship between full-time-culture and the outcome for quality and safety of care.

Design/methodology/approach

The paper is a literature review with a qualitatively oriented thematic analysis concerning quality or safety outcomes for patients, or patients and staff when introducing a full-time culture.

Findings

Identified factors that could have a positive or negative impact on quality and patient safety when introducing full-time culture were length of shift, fatigue/burnout, autonomy/empowerment and system/structure. Working shifts over 12 h or more than 40 h a week is associated with increased adverse events and errors, lower quality patient care, less attention to safety concerns and more care left undone. Long shifts give healthcare personnel more flexibility and better quality-time off, but there is also an association between long shifts and fatigue or burnout. Having a choice and flexibility around shift patterns is a predictor of increased wellbeing and health.

Originality/value

A major challenge across healthcare services is having enough qualified personnel to handle the increasing number of patients. One of the measures to get enough qualified personnel for the expected tasks is to increase the number of full-time employees and move towards a full-time culture. It is argued that full-time culture will have a positive effect on work environment, efficiency and quality due to a better allocation of work tasks, predictable work schedule, reduced sick leave, and continuity in treatment and care. There is limited research on how the introduction of full-time culture will affect the quality and safety for patients and staff, and few studies have been focusing on the relationship between longer shift, work schedule, and quality and safety of care.

Feasibility, performance and acceptability of an innovative vital signs monitor for sick newborns in Western Kenya: A mixed-methods study

Introduction

Low- and middle-income countries (LMICs) account for 99% of the global neonatal mortality. Limited access to advanced technology, such as bedside patient monitors contributes to disproportionately poor outcomes for critically ill newborns in LMICs. We designed a study to assess the feasibility, performance, and acceptability of a low-cost wireless wearable technology for continuous monitoring of sick newborns in resource-limited settings.

Methods

This was a mixed-methods implementation study conducted between March and April 2021 at two health facilities in Western Kenya. Inclusion criteria for newborns monitored included: age 0 to 28 days, birthweight ≥2.0 kg, low-to-moderate severity of illness at admission and the guardian's willingness to provide informed consent. Medical staff who participated in monitoring the newborns were surveyed about their experience with the technology. We used descriptive statistics to summarize our quantitative findings and qualitative data was coded and analyzed as an iterative process to summarize quotes on user acceptability.

Results

The results of the study demonstrated that adoption of neoGuard was feasible and acceptable in this setting. Medical staff described the technology as safe, user-friendly and efficient, after successfully monitoring 134 newborns. Despite the positive user experience, we did observe some notable technology performance issues such as a high percentage of missing vital signs data.

Conclusion

The results of this study were critical in informing the iterative process of refining and validating an innovative vital signs monitor for patients in resource-limited settings. Further research and development are underway to optimize neoGuard's performance and to examine its clinical impact and cost effectiveness.

The transcultural adaptation and validation of the Chinese version of the Attitudes Toward Recognizing Early and Noticeable Deterioration scale

Background

In China, clinical deterioration events present a real problem for every clinical nurse. Patient deterioration is determined in part by nurses' attitudes toward early recognition of clinical deterioration. However, research on attitudes toward the early identification of clinical deterioration is still in its infancy, and even less research has been done on ward nurses' attitudes toward the early identification of clinical deterioration. To drive behavioral change and improve the care of deteriorating patients, nurses need comprehensive, valid, and reliable tools to assess their attitudes toward early identification of deterioration.

Objective

In this study, we aimed to translate the Attitudes Toward Recognizing Early and Noticeable Deterioration (ATREND) scale into Chinese and to assess its validity and reliability tests.

Methods

From March 2022 to July 2022, the ATREND scale was translated, back-translated, and cross-culturally adapted into the Chinese version using a modified Brislin translation model. Then, 460 ward nurses were recruited from tertiary Grade A general hospitals in two cities: Shenyang and Jinzhou in Liaoning Province, China. Reliability analyses were conducted using internal consistency, split-half, and test-retest reliability. We convened a committee of experts to determine the validity of the content. Tests of the structural validity of the scale were conducted using exploratory and validation factor analyses.

Results

The Cronbach's α value of the Chinese version of the ATREND scale was 0.804, and the Cronbach's α value of the dimensions ranged from 0.782 to 0.863. The split-half reliability and test-retest reliability were 0.846 and 0.711, respectively. Furthermore, the scale has an index of content validity of 0.922, indicating a high level of content validity. In exploratory factor analysis, eigenvalues, total variance explained, and scree plot supported a three-factor structure. The three-factor model supported by this study was confirmed by confirmatory factor analysis (CFA). Moreover, the model fitting indexes (e.g., χ ²/DF = 1.498, GFI = 0.954, RMSEA = 0.047) were all within acceptable limits based on the CFA.

Conclusion

The Chinese version of the scale is reliable and valid among ward nurses. Nursing educators and clinicians will be able to develop targeted educational programs to enhance the competence and behaviors of Chinese ward nurses in recognizing clinical deterioration. It will be based on the developed scale to assess Chinese nurses' attitudes and practices regarding early recognition of clinical deterioration. As a result, it is necessary to consider the Chinese scale's three-factor structure. The developed three-factor structured scale will assess Chinese ward nurses' attitudes and practices toward patient observation and vital sign-monitoring empowerment, enlightening them on the importance of patient observation, encouraging ward nurses to use a wider range of patient assessment techniques to capture early signs of clinical deterioration, and helping ward nurses to develop clinical confidence to monitor clinical deterioration.

Ambulatory Oncology Nurses Weigh in About 12-Hour Shifts

BACKGROUND

Studies conducted in hospital settings have associated negative clinical outcomes with 12-hour shifts. Despite this, 12-hour shifts are common in nursing and popular among nurses. Little is known about outcomes associated with 12-hour shifts in ambulatory care settings.

OBJECTIVE

A mixed-methods, quality improvement project was conducted in a large, ambulatory cancer center to evaluate oncology nursing staff perspectives on 12-hour shift work.

METHODS

One hundred ambulatory oncology nurses completed surveys and 11 participated in focus group interviews.

FINDINGS

Nurses expressed predominately positive perspectives about 12-hour shift work in ambulatory oncology care.

CONCLUSIONS

Ambulatory oncology nurses perceived benefits to quality, safety, and satisfaction for both nurses and patients related to 12-hour shifts. Further evaluation of patient, nurse, and organizational outcomes unique to ambulatory settings is essential for nurse executives in formulating data-driven staffing plans. The incorporation of 12-hour shifts should be considered.

The clinical neglect of vital signs' assessment: an emerging patient safety issue?

OBJECTIVE

Vital signs assessment is a critical component of acute clinical care. Despite this, research has consistently found that the assessment of these signs is often neglected in clinical practice. This paper highlights three recent cases in the media where the neglect of vital signs assessment resulted in patient mortality.

RESULTS

Recent media reports highlighted the potentially devastating consequences of vital signs not being rigorously assessed including avoidable death. The public needs to be confident they will receive safe, quality health care when admitted to hospital.

CONCLUSION

The neglect of vital signs assessment places patients at risk of poor outcomes. Early detection of clinical deterioration via the assessment of vital signs facilitates prompt medical intervention. Factors contributing to the neglect of vital signs assessment need to be identified and corrective action taken to improve the safety of clinical care.

Consensus on patient cases for hospitalised children with a high paediatric track and trigger tool score that raises no mounting concern: a Delphi process study

BACKGROUND

Paediatric track and trigger tools (PTTTs) based on vital parameters have been implemented in hospitals worldwide to help healthcare professionals identify signs of critical illness and incipient deterioration in hospitalised children. It has been documented that nurses do not use PTTT as intended, but deviate from PTTT protocols because, in some situations, PTTT observations make little sense to them. The present study aimed to reach consensus on whether automatically generated PTTT scores that are higher than deemed reasonable by healthcare professionals according to their professional experience and clinical expertise may be downgraded.

METHODS

A two-round modified Delphi technique was used to explore consensus on 14 patient cases for hospitalised children with a high PTTT score that did not raise concerns by systematically collating questionnaire responses. Participants rated their level of agreement on a 9-point Likert scale. IQR and median were calculated for each case.

FINDINGS

A total of 221 participants completed round 1 and 101 participants completed round 2. Across the two rounds, majority of the participants were from paediatric departments, nurses and women. In round 1, consensus on inclusion was reached on 2 of the 14 cases. In round 2, consensus was reached on one additional patient case. Three of the 11 non-consensus cases remaining after rounds 1 and 2 were included by the research group based on predefined criteria.

CONCLUSION

In conclusion, a consensus opinion was achieved on six patient cases where the child had a high PTTT score but where the healthcare professionals were not as concerned as indicated by the PTTT score.

Attitudes and practices towards vital signs monitoring on paediatric wards: Cross-validation of the Ped-V scale

PURPOSE

To develop and psychometrically test an instrument measuring the attitudes and practices towards vital signs (VS) monitoring in nurses caring for children on paediatric wards (Ped-V scale).

DESIGN AND METHODS

This is a multicentre cross-validation study with a cross-sectional design. The Ped-V scale was developed by adapting the V-scale to the paediatric context and administered to a convenience sample of clinical nurses working in paediatric wards from January to May 2020. The content validity of the Ped-V scale was evaluated by a group of 10 experts. The psychometric properties of the scale were tested through Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA).

RESULTS

Overall, 10 Italian hospitals participated in the study, and 640 questionnaires were completed (87% female). At EFA a 30-item version of the scale and four factors emerged. This solution was confirmed at CFA: F1) 'Inaccuracy of VS monitoring and workload'; F2) 'Clinical competence and communication'; F3) 'Standardization and protocol adherence'; F4) 'Misconceptions about key indicators'. Cronbach's alpha ranged between 0.63 and 0.85.

CONCLUSIONS

The Ped-V scale is valid and reliable for use in the paediatric context to identify barriers concerning nurses' self-efficacy, competences, and knowledge of clinical indicators of paediatric critical deterioration, attitudes towards accuracy, standardization, communication to senior team members and the appropriate use of technology in paediatric VS monitoring.

PRACTICE IMPLICATIONS

The Ped-V scale may assist in identifying gaps in nurses' attitudes and devising strategies to change nurses' beliefs, knowledge, skills and decreasing individual, local cultural or organizational barriers towards VS monitoring.

How Routine are Routine Vital Signs?

BACKGROUND AND OBJECTIVES

Frequent measurement of vital signs has been associated with disruptions to sleep and increased nursing workload. Since vital signs are often measured at the same frequency regardless of patient acuity, there may be inappropriate prioritization of limited resources. We sought to understand what hospitalists report as the default frequency of routine vital sign measurement in hospitalized pediatric patients at academic institutions.

METHODS

We surveyed pediatric hospital medicine leadership at Association of American Medical Colleges-affiliated medical schools on their perception of routine vital signs in general medicine inpatients.

RESULTS

Survey requests were sent to individuals representing 140 unique hospitals. Responses were received from 74 hospitalists, representing a 53% response rate. Routine vitals were most commonly characterized as those collected every 4 hours (78%; 95% confidence interval, 67%-87%), though at least 1 in 5 hospitalists reported obtaining all or select vital signs (eg, blood pressure) less frequently. Strategies to decrease vital sign frequency varied.

CONCLUSIONS

Our results suggest routine vital signs are not a normative concept across all patient populations in pediatrics. We further identify several conditions under which deviation from routines are sanctioned.

Because they're worth it? A discussion paper on the value of 12-h shifts for hospital nursing

The organisation of the 24-h day for hospital nurses in two 12-h shifts has been introduced with value propositions of reduced staffing costs, better quality of care, more efficient work organisation, and increased nurse recruitment and retention. While existing reviews consider the impact of 12-h shifts on nurses' wellbeing and performance, this discussion paper aims to specifically shed light on whether the current evidence supports the value propositions around 12-h shifts. We found little evidence of the value propositions being realised. Staffing costs are not reduced with 12-h shifts, and outcomes related to productivity and efficiency, including sickness absence and missed nursing care are negatively affected. Nurses working 12-h shifts do not perform more safely than their counterparts working shorter shifts, with evidence pointing to a likely negative effect on safe care due to increased fatigue and sleepiness. In addition, nurses working 12-h shifts may have access to fewer educational opportunities than nurses working shorter shifts. Despite some nurses preferring 12-h shifts, the literature does not indicate that this shift pattern leads to increased recruitment, with studies reporting that nurses working long shifts are more likely to express intention to leave their job. In conclusion, there is little if any support for the value propositions that were advanced when 12-h shifts were introduced. While 12-h shifts might be here to stay, it is important that the limitations, including reduced productivity and efficiency, are recognised and accepted by those in charge of implementing schedules for hospital nurses.

The principles of whole-hospital predictive analytics monitoring for clinical medicine originated in the neonatal ICU

In 2011, a multicenter group spearheaded at the University of Virginia demonstrated reduced mortality from real-time continuous cardiorespiratory monitoring in the neonatal ICU using what we now call Artificial Intelligence, Big Data, and Machine Learning. The large, randomized heart rate characteristics trial made real, for the first time that we know of, the promise that early detection of illness would allow earlier and more effective intervention and improved patient outcomes. Currently, though, we hear as much of failures as we do of successes in the rapidly growing field of predictive analytics monitoring that has followed. This Perspective aims to describe the principles of how we developed heart rate characteristics monitoring for neonatal sepsis and then applied them throughout adult ICU and hospital medicine. It primarily reflects the work since the 1990s of the University of Virginia group: the theme is that sudden and catastrophic deteriorations can be preceded by subclinical but measurable physiological changes apparent in the continuous cardiorespiratory monitoring and electronic health record.

Event Prediction Model Considering Time and Input Error Using Electronic Medical Records in the Intensive Care Unit: Retrospective Study

BACKGROUND

In the era of artificial intelligence, event prediction models are abundant. However, considering the limitation of the electronic medical record-based model, including the temporally skewed prediction and the record itself, these models could be delayed or could yield errors.

OBJECTIVE

In this study, we aim to develop multiple event prediction models in intensive care units to overcome their temporal skewness and evaluate their robustness against delayed and erroneous input.

METHODS

A total of 21,738 patients were included in the development cohort. Three events-death, sepsis, and acute kidney injury-were predicted. To overcome the temporal skewness, we developed three models for each event, which predicted the events in advance of three prespecified timepoints. Additionally, to evaluate the robustness against input error and delays, we added simulated errors and delayed input and calculated changes in the area under the receiver operating characteristic curve (AUROC) values.

RESULTS

Most of the AUROC and area under the precision-recall curve values of each model were higher than those of the conventional scores, as well as other machine learning models previously used. In the error input experiment, except for our proposed model, an increase in the noise added to the model lowered the resulting AUROC value. However, the delayed input did not show the performance decreased in this experiment.

CONCLUSIONS

For a prediction model that was applicable in the real world, we considered not only performance but also temporal skewness, delayed input, and input error.

Nurses' experiences and preferences around shift patterns: A scoping review

Objective

To explore the evidence on nurses’ experiences and preferences around shift patterns in the international literature.

Data sources

Electronic databases (CINHAL, MEDLINE and Scopus) were searched to identify primary studies up to April 2021.

Methods

Papers reporting qualitative or quantitative studies exploring the subjective experience and/or preferences of nurses around shift patterns were considered, with no restrictions on methods, date or setting. Key study features were extracted including setting, design and results. Findings were organised thematically by key features of shift work.

Results

30 relevant papers were published between 1993 and 2021. They contained mostly qualitative studies where nurses reflected on their experience and preferences around shift patterns. The studies reported on three major aspects of shift work: shift work per se (i.e. the mere fact of working shift), shift length, and time of shift. Across all three aspects of shift work, nurses strive to deliver high quality of care despite facing intense working conditions, experiencing physical and mental fatigue or exhaustion. Preference for or adaptation to a specific shift pattern is facilitated when nurses are consulted before its implementation or have a certain autonomy to self-roster. Days off work tend to mitigate the adverse effects of working (short, long, early or night) shifts. How shift work and patterns impact on experiences and preferences seems to also vary according to nurses’ personal characteristics and circumstances (e.g. age, caring responsibilities, years of experience).

Conclusions

Shift patterns are often organised in ways that are detrimental to nurses’ health and wellbeing, their job performance, and the patient care they provide. Further research should explore the extent to which nurses’ preferences are considered when choosing or being imposed shift work patterns. Research should also strive to better describe and address the constraints nurses face when it comes to choice around shift patterns.

Impact of Hospital Nurses' Perception on Clinical Alarms and Patient Safety Culture on Alarm Management Practice

This study aimed to identify the impact of nurses' perception of clinical alarms and patient safety culture on alarm management. Additionally, we aimed to describe the importance of clinical alarm issues. The data were collected from 21 August to 10 September 2020. The study participants were 116 nurses working in a tertiary acute care hospital in Korea. The self-report questionnaire included general characteristics, clinical alarm issues, nurses' alarm perception, patient safety culture, and alarm management practice. The mean age of nurses was 28.04 ± 4.06 years, with 5.71 ± 4.35 years of total clinical experience. For the importance of alarm issues, frequent false alarms leading to reduced attention or response was the most important issue. Hierarchical linear regression analysis revealed that a higher level of nurses' perceived patient safety culture was the strongest predictor of better alarm management practice (p < 0.001), followed by their perception of clinical alarms (p = 0.034). In addition, female nurses (p = 0.004), charge nurses (p = 0.013), and nurses who work less than 40 h per week (p = 0.008) were more likely to work better in alarm management practice. Future studies are needed to develop standardized alarm management guidelines by improving nurses' positive perceptions of clinical alarms and patient safety culture.

Impact of a change in rostering practices on absenteeism: An observational descriptive study

Background:

There was a change in rostering practice from a regular three-shift system to an irregular three-shift system.

Objective:

This study observed the trend of absenteeism before and after a change in rostering practice.

Methods:

An observational design was used to collect sick-leave data from six months before the change in rostering practice to 12 months after. The average number of sick-leave days per month before and after the change were compared. Data for nursing hours per patient day (NHPPD) were also collected.

Results:

An increase in the number of sick-leave days was seen in three out of five wards following the change in rostering practice. Average sick leave across the five wards increased from 173.7 days per month before the change to 213.4 days per month after the change. Data for NHPPD showed no drastic change in manpower (e.g. resignation/training leave) during this period.

Conclusions:

There was an observed increase in absenteeism following the change in the rostering practice of nurses.

Strengthening tRansparent reporting of reseArch on uNfinished nursing CARE: The RANCARE guideline

Unfinished, rationed, missed, or otherwise undone nursing care is a phenomenon observed across health-care settings worldwide. Irrespective of differing terminology, it has repeatedly been linked to adverse outcomes for both patients and nursing staff. With growing numbers of publications on the topic, scholars have acknowledged persistent barriers to meaningful comparison across studies, settings, and health-care systems. The aim of this study was thus to develop a guideline to strengthen transparent reporting in research on unfinished nursing care. An international four-person steering group led a consensus process including a two-round online Delphi survey and a workshop with 38 international experts. The study was embedded in the RANCARE COST Action: Rationing Missed Nursing Care: An international and multidimensional Problem. Participation was voluntary. The resulting 40-item RANCARE guideline provides recommendations for transparent and comprehensive reporting on unfinished nursing care regarding conceptualization, measurement, contextual information, and data analyses. By increasing the transparency and comprehensiveness in reporting of studies on unfinished nursing care, the RANCARE guideline supports efficient use of the research results, for example, allowing researchers and nurses to take purposeful actions, with the goal of improving the safety and quality of health-care services.

Wearability Testing of Ambulatory Vital Sign Monitoring Devices: Prospective Observational Cohort Study

Background

Timely recognition of patient deterioration remains challenging. Ambulatory monitoring systems (AMSs) may provide support to current monitoring practices; however, they need to be thoroughly tested before implementation in the clinical environment for early detection of deterioration.

Objective

The objective of this study was to assess the wearability of a selection of commercially available AMSs to inform a future prospective study of ambulatory vital sign monitors in an acute hospital ward.

Methods

Five pulse oximeters (4 with finger probes and 1 wrist-worn only, collecting pulse rates and oxygen saturation) and 2 chest patches (collecting heart rates and respiratory rates) were selected to be part of this study: The 2 chest-worn patches were VitalPatch (VitalConnect) and Peerbridge Cor (Peerbridge); the 4 wrist-worn devices with finger probe were Nonin WristOx2 3150 (Nonin), Checkme O2+ (Viatom Technology), PC-68B, and AP-20 (both from Creative Medical); and the 1 solely wrist-worn device was Wavelet (Wavelet Health). Adult participants wore each device for up to 72 hours while performing usual “activities of daily living” and were asked to score the perceived exertion and perception of pain or discomfort by using the Borg CR-10 scale; thoughts and feelings caused by the AMS using the Comfort Rating Scale (CRS); and to provide general free text feedback. Median and IQRs were reported and nonparametric tests were used to assess differences between the devices’ CRS scores.

Results

Quantitative scores and feedback were collected in 70 completed questionnaires from 20 healthy volunteers, with each device tested approximately 10 times. The Wavelet seemed to be the most wearable device (P<.001) with an overall median (IQR) CRS score of 1.00 (0.88). There were no statistically significant differences in wearability between the chest patches in the CRS total score; however, the VitalPatch was superior in the Attachment section (P=.04) with a median (IQR) score of 3.00 (1.00). General pain and discomfort scores and total percentage of time worn are also reflective of this.

Conclusions

Our results suggest that adult participants prefer to wear wrist-worn pulse oximeters without a probe compressing the fingertip and they prefer to wear a smaller chest patch. A compromise between wearability, reliability, and accuracy should be made for successful and practical integration of AMSs within the hospital environment.

Symptoms of Anxiety, Depression, and Peritraumatic Dissociation in Critical Care Clinicians Managing Patients with COVID-19. A Cross-Sectional Study

Rationale: Frontline healthcare providers (HCPs) during the coronavirus disease (COVID-19) pandemic are at high risk of mental morbidity.

Objectives: To assess the prevalence of symptoms of anxiety, depression, and peritraumatic dissociation in HCPs.

Methods: This was a cross-sectional study in 21 ICUs in France between April 20, 2020, and May 21, 2020. The Hospital Anxiety and Depression Scale and the Peritraumatic Dissociative Experience Questionnaire were used. Factors independently associated with reported symptoms of mental health disorders were identified.

Measurements and Main Results: The response rate was 67%, with 1,058 respondents (median age 33 yr; 71% women; 68% nursing staff). The prevalence of symptoms of anxiety, depression, and peritraumatic dissociation was 50.4%, 30.4%, and 32%, respectively, with the highest rates in nurses. By multivariable analysis, male sex was independently associated with lower prevalence of symptoms of anxiety, depression, and peritraumatic dissociation (odds ratio of 0.58 [95% confidence interval, 0.42–0.79], 0.57 [95% confidence interval, 0.39–0.82], and 0.49 [95% confidence interval, 0.34–0.72], respectively). HCPs working in non–university-affiliated hospitals and nursing assistants were at high risk of symptoms of anxiety and peritraumatic dissociation. Importantly, we identified the following six modifiable determinants of symptoms of mental health disorders: fear of being infected, inability to rest, inability to care for family, struggling with difficult emotions, regret about the restrictions in visitation policies, and witnessing hasty end-of-life decisions.

Conclusions: HCPs experience high levels of psychological burden during the COVID-19 pandemic. Hospitals, ICU directors, and ICU staff must devise strategies to overcome the modifiable determinants of adverse mental illness symptoms.

The association between 12-hour shifts and nurses-in-charge's perceptions of missed care and staffing adequacy: a retrospective cross-sectional observational study

Background

Due to worldwide nursing shortages and difficulty retaining staff, long shifts for nursing staff (both registered nurses and nursing assistants) working in hospitals have been adopted widely. Because long shifts reduce the daily number of shifts from three to two, many assume that long shifts improve productivity by removing one handover and staff overlap. However, it is unclear whether staffing levels are more likely to be perceived as adequate when more long shifts are used.

Objectives

To investigate the association between the proportion of long (≥12‐hour) shifts worked on a ward and nurses-in-charge's perceptions that the staffing level was sufficient to meet patient need.

Methods

A retrospective cross-sectional study using routinely collected data (patient administrative data and rosters) linked to nurses-in-charge's reports from 81 wards within four English hospitals across 1 year (2017). Hierarchical logistic regression models were used to determine associations between the proportion of long shifts and nurses-in-charge's reports of having enough staff for quality or leaving necessary nursing care undone, after controlling for the staffing level relative to demand (shortfall). We tested for interactions between staffing shortfall and the proportion of long shifts.

Results

The sample comprised 19648 ward days. On average across wards, 72% of shifts were long. With mixed short and long shifts, the odds of nurses-in-charge reporting that there were enough staff for quality were 14-17% lower than when all shifts were long. For example, the odds of reporting enough staff for quality with between 60-80% long shifts was 15% lower (95% confidence interval 2% to 27%) than with all long shifts. Associations with nursing care left undone were consistent with this pattern. Although including interactions between staffing shortfalls and the proportion of long shifts did not improve model fit, the effect of long shifts did appear to differ according to shortfall, with lower proportions of long shifts associated with benefits when staffing levels were high relative to current norms.

Conclusions

Rather than a clear distinction between wards using short and long shifts, we found that a mixed pattern operated on most days and wards, with no wards using all short shifts. We found that when wards use exclusively long shifts rather than a mixture, nurses-in-charge are more likely to judge that they have enough staff. However, the adverse effects of mixed shifts on perceptions of staffing adequacy may be reduced or eliminated by higher staffing levels.

ISRCTN 12307968.

Tweetable abstract

12-hour shifts in nursing: a mix of short and long shifts may be worse than all long shifts.

Characteristics of working hours and the risk of occupational injuries among hospital employees: a case-crossover study

Objectives:

We investigated the association of working hours with occupational injuries in hospital shift work.

Methods:

Registry data of occupational injuries of hospital employees from 11 towns and 6 hospital districts were linked to daily payroll data to obtain working hours for 37 days preceding the first incidence of the injury (N=18 700). A case-crossover design and associated matched-pair interval analysis were used to compare working hour characteristics for three separate hazard windows among the same subjects. Conditional logistic regression was used to calculate odds ratios (OR) with 95% confidence intervals (CI).

Results:

We found an elevated risk of an occupational injury for workdays with evening shifts (OR 1.09, 95% CI 1.03–1.14) and workdays following night shifts (OR 1.33, 95% CI 1.17–1.52). After excluding commuting injuries, the risk increased during the evening shifts (OR 1.15, 95% CI 1.09–1.23) and the work days following night shifts (OR 1.44, 95% CI 1.24–1.69), but was no more significant during the morning shifts. Injury risk increased following a week of ≥5 morning shifts or ≥3 evening shifts, but did not increase according to the number of preceding night shifts or quick returns. The length of the work shift (OR 1.22, CI 1.06–1.42) – not the length of the weekly working hours – was associated with an increased risk.

Conclusions:

The results indicate an increased occupational injury risk during the evening shifts and during work days following night shifts, with the risk increasing according to the number of evening but not night shifts.

[Hospital nursing personnel staffing and patient outcome]

OBJECTIVE

The purpose of this review is to comment on the association between hospital nursing personnel staffing and patient outcomes, including the avoidance of errors and complications.

METHODS

A literature search was carried out in the Medline database on publications from the last 10 years on nursing personnel staffing.

RESULTS

Only overviews and observational studies on the topic were available and no controlled or prospective surveys. Most investigators assumed that there was an inverse relationship between low nursing staff levels of hospital wards and intensive care and adverse outcomes, including higher mortality rates; however, there is no clear significance for this assumption and evidence-based definitive lower limits for nursing staff cannot be given due to a lack of randomized trials. The causes for unfavorable results in the case of inadequate nursing personnel staffing include hygiene deficiencies, orders not followed and unfulfilled nursing and monitoring measures. Furthermore, staff overload leads to staff dissatisfaction and burnout, which also has a negative impact on the results. Most studies required a maximum patient to nurse ratio of 2:1 for the intensive care unit and an average ratio of not more than 8:1 for surgical wards. With respect to these requirements, changing personnel needs must be considered depending on the current state of the patients being cared for, which enabled all investigators to require a flexible roster design; approval for fixed statutory lower limits for nursing staff was low. The level of education of the nursing staff also played an essential role as qualified nursing staff cannot be replaced at will by less qualified assistant staff.

CONCLUSION

The level of training and the number of the nursing personnel influence hospital mortality and adverse outcomes; however, there are no evidence-based lower levels for nursing staff for inpatient care and perhaps this cannot be the case due to the changing complexity of the patients admitted, the comorbidities and possible treatment complications. There is a considerable need for research.

The impact of nurse staffing levels and nurse's education on patient mortality in medical and surgical wards: an observational multicentre study

BACKGROUND

Growing evidence indicates that improved nurse staffing in acute hospitals is associated with lower hospital mortality. Current research is limited to studies using hospital level data or without proper adjustment for confounders which makes the translation to practice difficult.

METHOD

In this observational study we analysed retrospectively the control group of a stepped wedge randomised controlled trial concerning 14 medical and 14 surgical wards in seven Belgian hospitals. All patients admitted to these wards during the control period were included in this study. Pregnant patients or children below 17 years of age were excluded. In all patients, we collected age, crude ward mortality, unexpected death, cardiac arrest with Cardiopulmonary Resuscitation (CPR), and unplanned admission to the Intensive Care Unit (ICU). A composite mortality measure was constructed including unexpected death and death up to 72 h after cardiac arrest with CPR or unplanned ICU admission. Every 4 months we obtained, from 30 consecutive patient admissions across all wards, the Charlson comorbidity index. The amount of nursing hours per patient days (NHPPD) were calculated every day for 15 days, once every 4 months. Data were aggregated to the ward level resulting in 68 estimates across wards and time. Linear mixed models were used since they are most appropriate in case of clustered and repeated measures data.

RESULTS

The unexpected death rate was 1.80 per 1000 patients. Up to 0.76 per 1000 patients died after CPR and 0.62 per 1000 patients died after unplanned admission to the ICU. The mean composite mortality was 3.18 per 1000 patients. The mean NHPPD and proportion of nurse Bachelor hours were respectively 2.48 and 0.59. We found a negative association between the nursing hours per patient day and the composite mortality rate adjusted for possible confounders (B = - 2.771, p = 0.002). The proportion of nurse Bachelor hours was negatively correlated with the composite mortality rate in the same analysis (B = - 8.845, p = 0.023). Using the regression equation, we calculated theoretically optimal NHPPDs.

CONCLUSIONS

This study confirms the association between higher nurse staffing levels and lower patient mortality controlled for relevant confounders.

12-hr shifts in nursing: Do they remove unproductive time and information loss or do they reduce education and discussion opportunities for nurses? A cross-sectional study in 12 European countries

Aims and objectives

To examine the association between registered nurses' (referred to as “nurses” for brevity) shifts of 12 hr or more and presence of continuing educational programmes; ability to discuss patient care with other nurses; assignments that foster continuity of care; and patient care information being lost during handovers.

Background

The introduction of long shifts (i.e., shifts of 12 hr or more) remains controversial. While there are claims of efficiency, studies have shown long shifts to be associated with adverse effects on quality of care. Efficiency claims are predicated on the assumption that long shifts reduce overlaps between shifts; these overlaps are believed to be unproductive and dangerous. However, there are potentially valuable educational and communication activities that occur during these overlaps.

Design

Cross‐sectional survey of 31,627 nurses within 487 hospitals in 12 European countries.

Methods

The associations were measured through generalised linear mixed models. The study methods were compliant with the STROBE checklist.

Results

When nurses worked shifts of 12 hr or more, they were less likely to report having continuing educational programmes; and time to discuss patient care with other nurses, compared to nurses working 8 hr or less. Nurses working shifts of 12 hr or more were less likely to report assignments that foster continuity of care, albeit the association was not significant. Similarly, working long shifts was associated with reports of patient care information being lost during handovers, although association was not significant.

Conclusion

Working shifts of 12 hr or more is associated with reduced educational activities and fewer opportunities to discuss patient care, with potential negative consequences for safe and effective care.

Relevance to clinical practice

Implementation of long shifts should be questioned, as reduced opportunity to discuss care or participate in educational activities may jeopardise the quality and safety of care for patients.