Measuring the nursing workload in intensive care with the Nursing Activities Score (NAS): A prospective study in 16 hospitals in Belgium

Instruments to measure complexity of care based on nursing workload in intensive care units: A systematic review

OBJECTIVE

To establish an evidence-based recommendation on the use of validated scoring systems that measure nursing workload in relation to the complexity of care in adult Intensive Care Units.

METHODS

A systematic review based on the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) was conducted (PROSPERO registration: CRD42021251272). We searched for validation studies until July 2023 using the bibliographic databases CINAHL, Scopus, Pubmed, WOS, Cochrane Database, SCIELO, Cuiden and Cuidatge. Reference selection and data extraction was performed by two independent reviewers. The assessment of risk of bias was performed using QUADAS-2 and the overall quality according to COSMIN and GRADE approach.

RESULTS

We included 22 articles identifying 10 different scoring systems. Reliability, criterion validity and hypothesis testing were the most frequently measurement properties reported. The NAS was the only tool to demonstrate a Class A recommendation (the best performing instrument).

CONCLUSIONS

NAS is the best currently available scoring system to assess complexity of care from nursing workload in ICU. However, it barely met the criteria for a class A recommendation. Future efforts should be made to develop, evaluate, and implement new systems based on innovative approaches such as intensity or complexity of care.

IMPLICATIONS FOR CLINICAL PRACTICE

The results facilitate decision making as it establishes a ranking of which instruments are recommended, promising or not recommended to measure the nursing workload in the intensive care units.

Objective assessment of nursing workload in an intermediate care unit: A prospective observational study

OBJECTIVES

To systematically assess the nursing workload in an Intermediate Care Unit.

DESIGN

Single-centre prospective observational study. The nursing activities within the initial 72 h of hospitalization were recorded on a prespecified chart and standardized as activities/5 min/patient/day.

SETTING

This study was conducted at the Intermediate Care Unit of the Altovicentino Hospital (Italy) from September 1 to December 31, 2022.

MAIN OUTCOME MEASURE

We considered working overload as an average number of nursing activities/5 min/patient/day higher than the 85th percentile and investigated independent risk factors associated with it.

RESULTS

A total of 183 patients were included. During their hospital stay, the average number of nursing activities per patient was 30 per 5-minute interval per day (range: 22-40). On the first day of hospitalization, the primary activities were predominantly administrative and managerial tasks. In contrast, on the second day, activities related to therapeutic management and primary care predominated. Various scores related to the patient's condition, including comorbidity, functionality, frailty, intensity, and severity, were analyzed for their association with nursing workload using multivariate analysis. However, only the National Early Warning Score was found to be an independent risk factor for nursing workload overload (OR 1.399, 95 % CI 1.205-1.624, p < 0.001).

CONCLUSION

The study results demonstrated a significant variation in nursing workload within the same department. Subsequent studies are necessary to confirm the ability of the National Early Warning Score in predicting nursing over workload.

IMPLICATION FOR CLINICAL PRACTICE

This study provides a detailed analysis of nursing workload in intermediate care settings, emphasizing the need for adequate resource allocation due to the potential for rapid deterioration in patients' conditions. By correlating nursing activities with patient severity indices, such as the National Early Warning Score, the findings support more effective organizational strategies to enhance care for patients at high risk of health decline.

Prevalence and risk factors of the use of physical restraint and impact of a decision support tool: A before-and-after study

BACKGROUND

Physical restraint is frequently used in intensive care units to prevent patients' life-threatening removal of indwelling devices. In France, their use is poorly studied. Therefore, to evaluate the need for physical restraint, we have designed and implemented a decision support tool.

AIMS

Besides describing the prevalence of physical restraint use, this study aimed to assess whether the implementation of a nursing decision support tool had an impact on restraint use and to identify the factors associated with this use.

STUDY DESIGN

A large observational, multicentre study with a repeated one-day point prevalence design was conducted. All adult patients hospitalized in intensive care units were eligible for this study. Two study periods were planned: before (control period) and after (intervention period) the deployment of the decision support tool and staff training. A multilevel model was performed to consider the centre effect.

RESULTS

During the control period, 786 patients were included, and 510 were in the intervention period. The prevalence of physical restraint was 28% (95% CI: 25.1%-31.4%) and 25% (95% CI: 21.5%-29.1%) respectively (χ2 = 1.35; p = .24). Restraint was applied by the nurse and/or nurse assistant in 96% of cases in both periods, mainly to wrists (89% vs. 83%, p = .14). The patient-to-nurse ratio was significantly lower in the intervention period (1:3.0 ± 1 vs. 1:2.7 ± 0.7, p < .001). In multivariable analysis, mechanical ventilation was associated with physical restraint (aOR [95% CI] = 6.0 [3.5-10.2]).

CONCLUSION

The prevalence of physical restraint use in France was lower than expected. In our study, the decision support tool did not substantially impact physical restraint use. Hence, the decision support tool would deserve to be assessed in a randomized controlled trial.

RELEVANCE TO CLINICAL PRACTICE

The decision to physically restrain a patient could be protocolised and managed by critical care nurses. A regular evaluation of the level of sedation could allow the most deeply sedated patients to be exempted from physical restraint.

Nursing workload and severity of COVID-19 patients in the Intensive Care Unit

OBJECTIVE

To evaluate the workload and severity of patients in the Intensive Care Unit (ICU) with COVID-19.

METHOD

Cross-sectional, analytical study carried out in the ICU of a private hospital. All patients over the age of 18 with a diagnosis of COVID-19 admitted from September 2020 to June 2021 were included. Workload assessed by the Nursing Activities Score (NAS), and severity by the Sequential Organ Failure Assessment. Descriptive and inferential analyses were performed.

RESULTS

217 patients were included, mostly men, mean age 62.41 years, white, obese, non-smokers and sedentary. The average NAS was 84.79. Staffing was in line with legislation and NAS. NAS was not associated with severity. Severity was associated with higher age, gender, comorbidities, sedentary lifestyle, time on mechanical ventilation, hospitalization and death.

CONCLUSION

Workload was high and not associated with severity or outcomes. Severity was associated with demographic and clinical conditions. This study shows the importance of staff sizing, with a view to promoting safety and quality of care.

Retaining Healing Hands: A Transnational Study on Job Retention Interventions for the Healthcare Workforce

Healthcare organizations worldwide face challenges in retaining their healthcare workforce, with individual and organizational factors influencing their intentions to leave. This study conducted eight online co-creation workshops and four Delphi sessions to gain qualitative and in-depth insights into job retention interventions, involving healthcare workers, hospital managers, and policymakers. A thematic analysis was conducted, resulting in multiple interventions that were clustered in four pre-defined themes: professional and personal support, education, financial incentives, and regulatory measures. Professional and personal support interventions included regular interprofessional team meetings, leadership training programs, self-scheduling and sabbaticals, support for administrative and non-clinical work, and the provision of psychological counselling. Educational interventions encompassed facilitating development opportunities, periodic evaluations, onboarding, mentorship programs, and peer support groups. Financial incentives included the provision of competitive salaries, adequate infrastructure, extra benefits, transport possibilities, and permanent employment contracts. Regulatory measures addressed the need for complementary legislation across various levels, fixed healthcare worker-to-patient ratio, and instruments to monitor workload. To optimize retention strategies, healthcare organizations should tailor these interventions to address the unique factors influencing their workforce's intentions to leave within their specific context. The study concludes that combining personal and professional support, educational opportunities, financial incentives, and regulatory measures is necessary because there is no one-size-fits-all solution.

Alarm fatigue and perceived stress among critical care nurses in the intensive care units: Palestinian perspectives

OBJECTIVE

The frequency of alarms generated by monitors and other electro-medical devices is undeniably valuable but can simultaneously escalate the workload for healthcare professionals, potentially subjecting intensive care unit nurses to alarm fatigue. The aim of this study is to investigate alarm fatigue and stress levels among critical care nursing personnel. Additionally, the study aims to assess predictors for both alarm fatigue and perceived stress.

METHODOLOGY

A descriptive cross-sectional study recruited 187 Intensive Care Unit (ICU) nurses from hospitals located in the northern and central regions of the West Bank, Palestine. Data were gathered through online surveys due to logistic concerns using the Alarm Fatigue Scale and the Perceived Stress Scale. The research was conducted between November 2023 and January 2024.

RESULTS

The mean overall alarm fatigue score was 23.36 (SD = 5.57) out of 44. The study showed that 62.6% of the participating ICU nurses experience average to high degree of alarm fatigue, while 69.5% experience average to high levels of perceived stress. A significant positive Pearson correlation was found between stress and alarm fatigue (0.40, P < 0.01). Important predictors of alarm fatigue include perceived stress, nurse-to-patient ratio, gender, and years of experience, while important predictors of perceived stress include alarm fatigue, type of working shift and hospital unit.

CONCLUSION

Alarm fatigue can compromise the timely intervention required to prevent adverse outcomes by causing delayed responses or missed critical alarm, which can have major ramifications for patient safety. Addressing stress is crucial for mitigating alarm fatigue and fostering a supportive work environment to ensure optimal patient care. Consequently, exploring strategies to alleviate the negative impacts of alarm fatigue on critical care nurses' stress merits further investigation in future research studies.

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.

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

INTRODUCTION

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS FOR CLINICAL PRACTICE

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

Circadian Rhythms Characteristics of Nurses Providing Direct Patient Care: An Observational Study

Background

In today's modern world, longer working hours, shift work, and working at night have become major causes of the disruption of our natural circadian rhythms. This study aimed to investigate the effects of the type of shift work (rotating vs. fixed day), duty period (on-duty vs. off-duty), and working period within each shift (nighttime vs. daytime) on the circadian rhythm characteristics of nurses who provide direct patient care.

Methods

This cross-sectional study used a purposive sampling method. Cosinor analysis was applied to analyze the actigraphy data of nurses providing direct patient care for seven consecutive days. The linear mixed effects model was then used to determine any variances between shift type, duty period, and working period within each shift for the nurses.

Results

The mesor value did not differ according to nurses' shift type, duty period, and working period within each shift. The amplitude was statistically higher in on-duty nurses and in daytime working hours. The acrophase was significantly delayed in nighttime working hours. As well as nurses in rotating shift had experience.

Conclusion

Our findings revealed that the peak activity of nurses occurs significantly later at night while working and nurses working during nighttime hours may have a weaker or less distinct circadian rhythm. Thus, this study suggests that limits be placed on the number of rotating nighttime shifts for nurses.

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

BACKGROUND

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

AIM

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

Cost comparisons and factors related to cost per stay in intensive care units in Belgium

BACKGROUND

Given the variability of intensive care unit (ICU) costs in different countries and the importance of this information for guiding clinicians to effective treatment and to the organisation of ICUs at the national level, it is of value to gather data on this topic for analysis at the national level in Belgium. The objectives of the study were to assess the total cost of ICUs and the factors that influence the cost of ICUs in hospitals in Belgium.

METHODS

This was a retrospective cohort study using data collected from the ICUs of 17 Belgian hospitals from January 01 to December 31, 2018. A total of 18,235 adult ICU stays were included in the study. The data set was a compilation of inpatient information from analytical cost accounting of hospitals, medical discharge summaries, and length of stay data. The costs were evaluated as the expenses related to the management of hospital stays from the hospital's point of view. The cost from the hospital perspective was calculated using a cost accounting analytical methodology in full costing. We used multivariate linear regression to evaluate factors associated with total ICU cost per stay. The ICU cost was log-transformed before regression and geometric mean ratios (GMRs) were estimated for each factor.

RESULTS

The proportion of ICU beds to ward beds was a median [p25-p75] of 4.7% [4.4-5.9]. The proportion of indirect costs to total costs in the ICU was 12.1% [11.4-13.3]. The cost of nurses represented 57.2% [55.4-62.2] of direct costs and this was 15.9% [12.0-18.2] of the cost of nurses in the whole hospital. The median cost per stay was €4,267 [2,050-9,658] and was €2,160 [1,545-3,221] per ICU day. The main factors associated with higher cost per stay in ICU were Charlson score, mechanical ventilation, ECMO, continuous hemofiltration, length of stay, readmission, ICU mortality, hospitalisation in an academic hospital, and diagnosis of coma/convulsions or intoxication.

CONCLUSIONS

This study demonstrated that, despite the small proportion of ICU beds in relation to all services, the ICU represented a significant cost to the hospital. In addition, this study confirms that nursing staff represent a significant proportion of the direct costs of the ICU. Finally, the total cost per stay was also important but highly variable depending on the medical factors identified in our results.

Analysis of Nursing Staff Management for a Semi-intensive Pulmonology Unit During the COVID-19 Pandemic Using the Nursing Activities Score

OBJECTIVES

During the COVID-19 pandemic, a shortage of intensive care unit beds was encountered across Europe. Opening a semi-intensive pulmonary ward freed up intensive care unit beds. This study aimed to determine the appropriate nurse staffing level for a semi-intensive pulmonology unit (SIPU) for patients with COVID-19 and to identify factors associated with an increase in nursing workload in this type of unit.

METHODS

This was a retrospective study of the SIPU of the Erasme university clinics in Belgium. Nursing staff was determined with the Nursing Activities Score (NAS) during the second wave of COVID-19 in Belgium.

RESULTS

During the study period, 59 patients were admitted to the SIPU, and a total of 416 NAS scores were encoded. The mean (±SD) NAS was 70.3% (±16.6%). Total NAS varied significantly depending on the reason for admission: respiratory distress (mean [SD] NAS, 71.6% [±13.9%]) or critical illness-related weakness (65.1% ± 10.9%). The items encoded were significantly different depending on the reason for admission. In multivariate analysis, body mass index > 30 (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.07-3.30) and higher Simplified Acute Physiology Score II score (OR, 1.05; 95 CI, 1.02-1.11) were associated with higher NAS. Patients admitted via the emergency department (OR, 2.45; 95% CI, 1.15-5.22) had higher NAS. Patients on noninvasive ventilation (OR, 13.65; 95% CI, 3.76-49.5) and oxygen therapy (OR, 4.29; 95% CI, 1.27-14.48) had higher NAS. High peripheral venous oxygen saturation (OR, 0.86; 95% CI, 0.78-0.94) was a predictor of lower workload.

CONCLUSION

A ratio of 2 nurses to 3 patients is necessary for SIPU care of patients with COVID-19. Factors associated with higher workload were high Simplified Acute Physiology Score II score, body mass index > 30, admission via emergency room, patients on oxygen, and noninvasive ventilation.

Prevalence and factors associated with academic burnout risk among nursing and midwifery students during the COVID-19 pandemic: A cross-sectional study

AIM

The aim of the study was to assess the prevalence of academic burnout (AB) and its associated factors among nursing and midwifery students during the COVID-19 pandemic.

DESIGN

A correlational cross-sectional study.

METHODS

An online survey was distributed from November to December 2020 to nursing and midwifery students in Belgium. The risk of AB was assessed using the MBI-SS Academic Burnout Inventory scale. Factors associated with AB were related to the personal life and level of education of the student and to the COVID-19 pandemic.

RESULTS

The prevalence of overall AB risk was 50.0% (95% CI 48.5-53.1). Factors significantly associated with higher risk of AB were having a child, having a job, the level of academic training, working overtime, insufficient personal protective equipment against viral contamination during the last internship, work overload due to the pandemic, personal proven or possible SARS-CoV-2 infection and having a relative who died related to COVID-19.

Impact of Wound Dressing Changes on Nursing Workload in an Intensive Care Unit

The objective of this study is to understand how the type of wound dressing changes (routine or frequent) in patients admitted to intensive care units influences nurses' workload. This study used a database of retrospective and analytical observational study from one Portuguese intensive care unit. The sample included 728 adult patients admitted between 2015 and 2019. The nursing workload was assessed by the TISS-28 scale, both at admission and at discharge. The linear regression results show that patients with frequent dressing changes are associated with a higher nursing workload, both at admission (Coef. 1.65; 95% CI [0.53; 2.77]) and discharge (Coef. 1.27; 95% CI [0.32; 2.22]). In addition, age influences the nursing workload; older people are associated with a higher nursing workload (at admission Coef. 0.07; 95% CI [0.04; 0.10]; at discharge Coef. 0.08; 95% CI [0.05; 0.10]). Additionally, an increase in nursing workload at admission would significantly increase the nursing workload at discharge (Coef. 0.27; 95% CI [0.21; 0.33]). The relative stability of the nursing workload over the studied years is also another important finding (the influence of studied years is non-significant). In conclusion, patients with frequent dressing changes presented higher TISS-28 scores when compared with patients with an exchange of routine dressings, which leads to a higher nursing workload.

Nursing workload assessment in an intensive care unit: A retrospective observational study using the Nursing Activities Score

BACKGROUND

Nursing Activities Score (NAS) is a promising tool for calculating the nursing workload in intensive care units (ICU). However, data on intensive care nursing activities in Portugal are practically non-existent.

AIM

To assess the nursing workload in a Portuguese ICU using the NAS.

STUDY DESIGN

Retrospective cohort study developed throughout the analysis of the electronic health record database from 56 adult patients admitted to a six-bed Portuguese ICU between 1 June-31 August 2020. The nursing workload was assessed by the Portuguese version of the NAS. The study was approved by the Hospital Council Board and Ethics Committee. The study report followed the STROBE guidelines.

RESULTS

The average occupancy rate was 73.55% (±16.60%). The average nursing workload per participant was 67.52 (±10.91) points. There was a correlation between the occupancy rate and the nursing workload. In 35.78% of the days, the nursing workload was higher than the available human resources, overloading nurse staffing/team.

CONCLUSIONS

The nursing workload reported follows the trend of the international studies and the results reinforce the importance of adjusting the nursing staffing to the complexity of nursing care in this ICU. This study highlighted periods of nursing workload that could compromise patient safety.

RELEVANCE TO CLINICAL PRACTICE

This was one of the first studies carried out with the NAS after its cross-cultural adaptation and validation for the Portuguese population. The nursing workload at the patient level was higher in the first 24 h of ICU stays. Because of the 'administrative and management activities' related to the 'patient discharge procedures', the last 24 h of ICU stays also presented high levels of nursing workload. The implementation of a nurse-to-patient ratio of 1:1 may contribute to safer nurse staffing and to improve patient safety in this Tertiary (level 3) ICU.

Carga laboral de profesionales de enfermería en Unidad de Cuidado Intensivo según Nursing Activities Score

Highlights: La NAS es una herramienta que toma relevancia al momento de evaluar la carga de trabajo de los profesionales de enfermería. Se evidencia que el personal de enfermería está expuesto a altas cargas de trabajo que, en la mayoría de casos, supera lo sugerido por Consejos y Asociaciones de enfermería. Algunos factores que pueden afectar la carga de trabajo son el tipo de turnos de trabajo, sexo del profesional, tipo de UCI, el número de pacientes a cargo, entre otros. Es necesario evaluar la implementación de la NAS en distintos tipos de servicios para entender la situación y trabajo actual de los profesionales de enfermería. Introducción: Nursing Activities Score ha sido utilizada como un instrumento principalmente en la Unidad de Cuidados Intensivos para medir las actividades de enfermería, siendo esta la unidad que maneja pacientes de mayor complejidad para el cuidado. Objetivo: establecer la carga de trabajo, evaluada por Nursing Activities Score, y factores relacionados a la misma en Unidades de Cuidado Intensivo. Metodología: Revisión cualitativa tipo scoping Review, utilizando el método PRISMA. Búsqueda en las bases de datos CINAHL, LILACS, SCOPUS, SCIENCE DIRECT, SCIELO y PUBMED. Resultados: La muestra final se compone de 87 textos, que van desde el año 2007 hasta 2021. Se clasificaron en cinco categorías: Carga de trabajo en UCI, comparación entre unidades, carga de trabajo relacionada al personal de enfermería, carga de trabajo relacionada a las características de los pacientes y consecuencias de la carga de trabajo. Discusión: La revisión revela una carga de trabajo mayor al 50% en la mayoría de los estudios, esto debido a diferentes factores: principalmente las características particulares de los pacientes, no se observó una diferencia significativa entre unidades generales y especializadas, las cargas de trabajo elevadas suponen un factor de riesgo para la ocurrencia de eventos adversos. Conclusiones: Los resultados de esta revisión permiten evidenciar que el personal de enfermería está expuesto constantemente a altas cargas de trabajo. Esta carga de trabajo puede verse influenciada o influenciar diversos factores, como lo son las características de los pacientes a quienes se brinda atención o puede afectar positiva o negativamente la calidad de la atención de enfermería. Como citar este artículo: Cruz López Laura Nathalie, Quintero Osorio Jenny Fernanda, Melo Roa Juan David, Henao Castaño Ángela María. Carga laboral de profesionales de enfermería en Unidad de Cuidado Intensivo según Nursing Activities Score. Revista Cuidarte. 2023;14(1):e2680. http://dx.doi.org/10.15649/cuidarte.2680

Ambient intelligence-based monitoring of staff and patient activity in the intensive care unit

BACKGROUND

Caregiver workload in the ICU setting is difficult to numerically quantify. Ambient Intelligence utilises computer vision-guided neural networks to continuously monitor multiple datapoints in video feeds, has become increasingly efficient at automatically tracking various aspects of human movement.

OBJECTIVES

To assess the feasibility of using Ambient Intelligence to track and quantify allpatient and caregiver activity within a bedspace over the course of an ICU admission and also to establish patient specific factors, and environmental factors such as time ofday, that might contribute to an increased workload in ICU workers.

METHODS

5000 images were manually annotated and then used to train You Only LookOnce (YOLOv4), an open-source computer vision algorithm. Comparison of patientmotion and caregiver activity was then performed between these patients.

RESULTS

The algorithm was deployed on 14 patients comprising 1762800 framesof new, untrained data. There was a strong correlation between the number ofcaregivers in the room and the standardized movement of the patient (p < 0.0001) withmore caregivers associated with more movement. There was a significant difference incaregiver activity throughout the day (p < 0.05), HDU vs. ICU status (p < 0.05), delirious vs. non delirious patients (p < 0.05), and intubated vs. not intubated patients(p < 0.05). Caregiver activity was lowest between 0400 and 0800 (average .71 ± .026caregivers per hour) with statistically significant differences in activity compared to 0800-2400 (p < 0.05). Caregiver activity was highest between 1200 and 1600 (1.02 ± .031 caregivers per hour) with a statistically significant difference in activity comparedto activity from 1600 to 0800 (p < 0.05). The three most dominant predictors of workeractivity were patient motion (Standardized Dominance 78.6%), Mechanical Ventilation(Standardized Dominance 7.9%) and Delirium (Standardized Dominance 6.2%).

CONCLUSION

Ambient Intelligence could potentially be used to derive a single standardized metricthat could be applied to patients to illustrate their overall workload. This could be usedto predict workflow demands for better staff deployment, monitoring of caregiver workload, and potentially as a tool to predict burnout.

Association of burnout and intention-to-leave the profession with work environment: A nationwide cross-sectional study among Belgian intensive care nurses after two years of pandemic

BACKGROUND

Intensive care unit (ICU) nurses are at an increased risk of burnout and may have an intention-to-leave their jobs. The COVID-19 pandemic may increase this risk.

OBJECTIVE

The objective of this study was to describe the prevalence of burnout risk and intention-to-leave the job and nursing profession among ICU nurses and to analyse the relationships between these variables and the work environment after two years of the COVID-19 pandemic.

DESIGN

A national cross-sectional survey of all nurses working in Belgian ICUs was conducted between December 2021 and January 2022 during the 4th and 5th waves of the COVID-19 pandemic in Belgium. The Practice Environment Scale of the Nursing Work Index (PES-NWI) was used to measure the work environment, intention-to-leave the hospital and/or the profession was assessed. The risk of burnout was assessed using the Maslach Burnout Inventory scale including emotional exhaustion, depersonalisation, and reduced personal accomplishment.

SETTING

Nurses in 78 out of 123 Belgian hospital sites with an ICU participated in the survey.

PARTICIPANTS

2321 out of 4851 nurses (47.8%) completed the entire online survey.

RESULTS

The median overall risk of burnout per hospital site (high risk in all three subdimensions) was 17.6% [P25: 10.0 - P75: 28.8] and the median proportion of nurses with a high risk in at least one subdimension of burnout in Belgian ICUs was 71.6% [56.7-82.7]. A median of 42.9% [32.1-57.1] of ICU nurses stated that they intended-to-leave the job and 23.8% [15.4-36.8] stated an intent-to-leave the profession. The median overall score of agreement with the presence of positive aspects in the work environment was 49.0% [44.8-55.8]. Overall, nurses working in the top 25% of best-performing hospital sites with regard to work environment had a statistically significant lower risk of burnout and intention-to-leave the job and profession compared to those in the lowest performing 25% of hospital sites. Patient-to-nurse ratio in the worst performing quartile was associated with a higher risk for emotional exhaustion (OR = 1.53, 95% CI:1.04-2.26) and depersonalisation (OR = 1.48, 95% CI:1.03-2.13) and intention-to-leave the job (OR = 1.46, 95% CI:1.03-2.05).

CONCLUSIONS

In this study, a high prevalence of burnout risk and intention-to-leave the job and nursing profession was observed after two years of the COVID-19 pandemic. Nevertheless, there was substantial variation across hospital sites which was associated with the quality of the work environment.

TWEETABLE ABSTRACT

"Burnout & intention to leave was high for Belgian ICU nurses after 2 years of COVID, but wellbeing was better with high quality work environments and more favourable patient to nurse ratios".

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. .

Closed-loop oxygen control improves oxygen therapy in acute hypoxemic respiratory failure patients under high flow nasal oxygen: a randomized cross-over study (the HILOOP study)

Background

We aimed to assess the efficacy of a closed-loop oxygen control in critically ill patients with moderate to severe acute hypoxemic respiratory failure (AHRF) treated with high flow nasal oxygen (HFNO).

Methods

In this single-centre, single-blinded, randomized crossover study, adult patients with moderate to severe AHRF who were treated with HFNO (flow rate ≥ 40 L/min with FiO₂ ≥ 0.30) were randomly assigned to start with a 4-h period of closed-loop oxygen control or 4-h period of manual oxygen titration, after which each patient was switched to the alternate therapy. The primary outcome was the percentage of time spent in the individualized optimal SpO₂ range.

Results

Forty-five patients were included. Patients spent more time in the optimal SpO₂ range with closed-loop oxygen control compared with manual titrations of oxygen (96.5 [93.5 to 98.9] % vs. 89 [77.4 to 95.9] %; p < 0.0001) (difference estimate, 10.4 (95% confidence interval 5.2 to 17.2). Patients spent less time in the suboptimal range during closed-loop oxygen control, both above and below the cut-offs of the optimal SpO₂ range, and less time above the suboptimal range. Fewer number of manual adjustments per hour were needed with closed-loop oxygen control. The number of events of SpO₂ < 88% and < 85% were not significantly different between groups.

Conclusions

Closed-loop oxygen control improves oxygen administration in patients with moderate-to-severe AHRF treated with HFNO, increasing the percentage of time in the optimal oxygenation range and decreasing the workload of healthcare personnel. These results are especially relevant in a context of limited oxygen supply and high medical demand, such as the COVID-19 pandemic.

Trial registration The HILOOP study was registered at www.clinicaltrials.gov under the identifier NCT04965844.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03970-w.

Shifting Nursing Care Models as a Solution for the Increasing Demand on Intensive Care Unit Beds During a Pandemic: A Case Study

AIM

An option appraisal of different nursing care delivery models was presented, which were made in between the first and second COVID-19 waves. The authors wanted to inform colleagues on involving nursing care delivery models in the problem-solving process during a pandemic.

LOCAL PROBLEM

In the pre-COVID-19 hospital practice, the nursing care delivery model of primary nursing was applied in the intensive care unit (ICU). However, during the COVID-19 pandemic, this situation could not be upheld because of the increased need for ICU beds and the shortages of available ICU nurses.

METHODS

This study used the literature of an ongoing systematic review on nursing care delivery models and expert meetings between the authors and nursing staff.

RESULTS

One standard nursing care delivery model and 3 alternative nursing care delivery models were discussed and compared in this case study. Theoretically, a modular system of team nursing seemed the better model to use during a pandemic. This model leads to an equal distribution of expertise and social distancing between experts. Compared with the other models, a strategic reserve can be created.

CONCLUSION

This case study should be primarily considered as an example on how rethinking and reorganizing the nursing care delivery model could contribute to an enlarged, qualitative capacity, which needs to be organized in a short time span.

Associations between two nursing workload scales and the cost of intensive care unit nursing staff: A retrospective study of one Belgian hospital

AIMS

The aim of this study was to assess associations between a general nursing funding scale and an intensive care unit specific nursing workload scale and the cost of nursing staff.

BACKGROUND

Nurse staffing represents the most important cost in the intensive care unit, so it is essential to evaluate it accurately. In addition, the assessment of nursing workload is important for the daily management of the intensive care unit and to ensure quality of care.

METHODS

This was a retrospective and quantitative study carried out in the intensive care unit of a Belgian hospital. The extraction of data from the Nursing Activities Score and the Minimum Hospital Summary Nursing Dataset were carried out during 2 periods of 15 days, from 1 June 2018 to 15 June 2018 and from 1 September 2018 to 15 September 2018.

RESULTS

A total of 234 patients were included in the study. A total of 773 Nursing Activities Score and Minimum Hospital Summary Nursing Dataset recordings were analyzed in the study per intensive care unit day. A strong correlation was observed between Nursing Activities Score and Minimum Hospital Summary Nursing Dataset for the entire intensive care unit stay with a rho (95% CI) of .88 (0.83-.93); however, the correlation was moderate per intensive care unit day with a rho of .51 (0.45-0.57). A strong association was observed between the Minimum Hospital Summary Nursing Dataset and the Nursing Activities Score with the costs of intensive care unit nurses with a rho (95% CI) of .78 (0.72-0.86) and .74 (0.65-0.84), respectively.

CONCLUSIONS

A general nursing funding scale in Belgium was strongly correlated with the nursing workload for the whole intensive care unit stay, but this correlation was moderate per intensive care unit day. In contrast, both scales showed a good correlation with intensive care unit nursing costs.

IMPLICATIONS FOR NURSING MANAGEMENT

In Belgium, a general funding scale for nurses does not allow for an assessment of the nursing workload in the intensive care unit. The Nursing Activities Score is strongly correlated with the cost of nursing staff in the intensive care unit. The authors recommend that the Belgian authorities carry out this type of study in several intensive care units in the country and eventually replace the general funding scale for nurses with the Nursing Activities Score.

Nursing workload on the day of discharge from the intensive care unit is associated with readmission

PURPOSE

To verify whether there is an association between the Nursing Activities Score (NAS) on the day of discharge from the intensive care unit and readmission..

MATERIALS AND METHODS

A retrospective cohort study of all patients admitted to the intensive care unit of Hospital Ernesto Dornelles, Porto Alegre, Brazil, who were discharged to the ward from October 2018 to December 2019. We collected demographic and clinical variables of the patients and the Nursing Activities Scoreon the day of discharge. Patients were followed up until the day of hospital discharge or death.

RESULTS

We included 1045 patients in the final sample. One hundred eighty-eight (18.0%) patients were readmitted, in addition there were two (0.2%) unexpected deaths that occurred in the ward. The median NAS was 59.9 (50.9-67.3), which was higher in the bivariate analysis in patients who were readmitted (64.0, 55.7-71.4) than in patients who were not readmitted (58.7, 49.7-66.1) (p < 0.001). Patients with a Nursing Activities Score  ≥ 60.0 and < 60.0 had rates of readmission of 23.4% and 12.7%, respectively (p < 0.001). After multivariable adjustment, the Nursing Activities Score at discharge maintained an association with readmission. In addition, in the Cox regression, the Nursing Activities Score as a dichotomous variable was independently associated with readmission (adjusted HR 1.560; CI 1.146-2.125; p = 0.005).

CONCLUSIONS

We found that the nursing workload, assessed by the Nursing Activities Score at the time of discharge from the intensive care unit, was associated with risk of readmission..

Prevalence and Associated Factors of Burnout Risk Among Intensive Care and Emergency Nurses Before and During the Coronavirus Disease 2019 Pandemic: A Cross-Sectional Study in Belgium

INTRODUCTION

This study aimed to assess (1) the prevalence of burnout risk among nurses working in intensive care units and emergency department before and during the coronavirus disease 2019 pandemic and (2) the individual and work-related associated factors.

METHODS

Data were collected as part of a cross-sectional study on intensive care unit and emergency nurses in Belgium using 2 self-administered online questionnaires distributed just before the pandemic (January 2020, N = 422) and during the first peak of the pandemic (April 2020, N = 1616). Burnout was assessed with the Maslach Burnout Inventory scale.

RESULTS

The overall prevalence of burnout risk was higher among emergency nurses than intensive care unit nurses but was not significantly different after the coronavirus disease 2019 pandemic (from 69.8% to 70.7%, χ² = 0.15, P = .68), whereas it increased significantly among intensive care unit nurses (from 51.2% to 66.7%, χ² = 23.64, P < .003). During the pandemic, changes in workload and the lack of personal protective equipment were significantly associated with a higher likelihood of burnout risk, whereas social support from colleagues and from superiors and management were associated with a lower likelihood of burnout risk. Several determinants of burnout risk were different between intensive care unit and emergency nurses.

CONCLUSION

Our findings indicate that nurses in intensive care unit and emergency department were at risk of burnout but their experience during the coronavirus disease 2019 pandemic was quite different. Therefore, it is important to implement specific measures for these 2 groups of nurses to prevent and manage their risk of burnout.

The Polish Version of the Nursing Delirium Screening Scale (NuDESC PL)-Experience of Using in Nursing Practice in Cardiac Surgery Intensive Care Unit

Introduction: Delirium is a common complication of patients hospitalized in Intensive care units (ICU). The risk of delirium is estimated at approximately 80% in intensive care units. In the case of cardiac surgery ICU, the risk of delirium increases due to the type of procedures performed with the use of extracorporeal circulation. The aim of this study was to provide an official translation and evaluation of Nursing Delirium Screening Scale (NuDESC) into Polish. The NuDESC scale is a scale used by nurses around the world to detect delirium at an early stage in treatment. Methods: The method used in the study was the NuDESC tool, which was translated into Polish. The study was conducted by Cardiac ICU nurses during day shift (at 8 a.m.), night shift (at 8 p.m.) and in other situations where the patients showed delirium-like symptoms. Results: Statistically significant differences were observed between the first and second day in the studied group of patients in the case of illusions/hallucinations. Delirium occurred more frequently during the night, but statistical significance was demonstrated for both daytime and nighttime shifts. It was not demonstrated in relation to the NuDESC scale in the case of insomnia disorders. The diagnosis of delirium and disorientation was the most common diagnosis observed in patients on the first day of their stay in the ICU, followed by problems with communication. Delirium occurred on the first day, mainly at night. On the second day, delirium was much less frequent during the night; the biggest problem was disorientation and problems with communication. Conclusion: This study contributed to the development of the Polish version of the scale (NuDESC PL) which is now used as the Polish screening tool for delirium detection. The availability of an easy-to-use nurse-based delirium instrument is a prerequisite for widespread implementation.

Factors associated with nursing workload in three intensive care units

OBJECTIVE

To determine the nursing workload in intensive care units (ICUs) and the factors associated with the Nursing Activities Score (NAS).

METHOD

An analytical cross-sectional study was carried out in three ICUs in Bucaramanga, Colombia, between February 2018 and February 2020. The nursing workload was estimated based on the NAS. A descriptive and bivariate analysis stratified by ICU was performed using a robust multiple linear regression model, and the factors associated with the nursing workload (p < 0.05) were estimated.

RESULTS

In this study, 362 records were included. The median NAS was 68.1 points (Q1:47.2-Q3:116.7). APACHE II (β = 3.13, CI: 95% 2.28; 3.98), days of stay in ICU ≥3 (β = 16.78, CI: 95% 6.15; 27.41), surgery provenance service (β = 22.31, CI: 95% 9.76; 34.86), and traumatology and emergencies diagnostic category (β = 33.72, CI 95%: 9.90; 57.53) were associated with high NAS scores.

CONCLUSION

The nursing staff spend approximately 70% of their time on a single patient, and administrative work takes up most of their time. Hospital stays of longer than 3 days, high APACHE II score, coming from the surgery department, and having a diagnosis of trauma and emergency were associated with a high workload.

The impact of COVID-19 on nursing workload and planning of nursing staff on the Intensive Care: A prospective descriptive multicenter study

INTRODUCTION

The impact of the care for COVID-19 patients on nursing workload and planning nursing staff on the Intensive Care Unit has been huge. Nurses were confronted with a high workload and an increase in the number of patients per nurse they had to take care of.

OBJECTIVE

The primary aim of this study is to describe differences in the planning of nursing staff on the Intensive Care in the COVID period versus a recent non-COVID period. The secondary aim was to describe differences in nursing workload in COVID-19 patients, pneumonia patients and other patients on the Intensive Care. We finally wanted to assess the cause of possible differences in Nursing Activities Scores between the different groups.

METHODS

We analyzed data on nursing staff and nursing workload as measured by the Nursing Activities Score of 3,994 patients and 36,827 different shifts in 6 different hospitals in the Netherlands. We compared data from the COVID-19 period, March 1st 2020 till July 1st 2020, with data in a non-COVID period, March 1st 2019 till July 1st 2019. We analyzed the Nursing Activities Score per patient, the number of patients per nurse and the Nursing Activities Score per nurse in the different cohorts and time periods. Differences were tested by a Chi-square, non-parametric Wilcoxon or Student's t-test dependent on the distribution of the data.

RESULTS

Our results showed both a significant higher number of patients per nurse (1.1 versus 1.0, p<0.001) and a significant higher Nursing Activities Score per Intensive Care nurse (76.5 versus 50.0, p<0.001) in the COVID-19 period compared to the non-COVID period. The Nursing Activities Score was significantly higher in COVID-19 patients compared to both the pneumonia patients (55.2 versus 50.0, p<0.001) and the non-COVID patients (55.2 versus 42.6, p<0.001), mainly due to more intense hygienic procedures, mobilization and positioning, support and care for relatives and respiratory care.

CONCLUSION

With this study we showed the impact of COVID-19 patients on the planning of nursing care on the Intensive Care. The COVID-19 patients caused a high nursing workload, both in number of patients per nurse and in Nursing Activities Score per nurse.

Prevalence of burnout risk and factors associated with burnout risk among ICU nurses during the COVID-19 outbreak in French speaking Belgium

OBJECTIVE

Burnout is a global work-related phenomenon. Intensive care unit (ICU) nurses are at risk of burnout and the COVID-19 pandemic may increase this risk. The objectives of this study were to assess the prevalence of burnout risk and identify risk factors among ICU nurses during the COVID-19 pandemic.

RESEARCH METHODOLOGY

Web-based survey performed during the first wave of the COVID-19 pandemic in French speaking Belgium.

MAIN OUTCOME MEASURES

Risk of burnout was assessed with the Maslach Burnout Inventory scale.

RESULTS

A total of 1135 ICU nurses responded to the questionnaire. The overall prevalence of burnout risk was 68%. A total of 29% of ICU nurses were at risk of depersonalisation (DP), 31% of reduced personal accomplishment (PA), and 38% of emotional exhaustion (EE). A 1:3 nurse-to-patient ratio increased the risk of EE (OR = 1.77, 95% CI: 1.07-2.95) and DP (OR = 1.38, 95% CI: 1.09-2.40). Those who reported having a higher perceived workload during the COVID-19 pandemic were at higher risk for all dimensions of burnout. Shortage of personal protective equipment increased the risk of EE (OR = 1.78, 95% CI: 1.35-3.34) and nurses who reported having symptoms of COVID-19 without being tested were at higher risk of EE (OR = 1.40, 95% CI: 1.68-1.87).

CONCLUSIONS

Two-thirds of ICU nurses were at risk of burnout and this risk was associated with their working conditions during the first wave of the COVID-19 pandemic. We recommend monitoring the risk of burnout and implementing interventions to prevent and manage it, taking into account the factors identified in this study.

Assessment of Nursing Workload as a Mortality Predictor in Intensive Care Units (ICU) Using the Nursing Activities Score (NAS) Scale

Introduction: Nursing activities score scales are valuable instruments for assessing the quality of nursing care provided in critically ill patients and easy to use in validating nurse staffing. The aim of this study was the assessment of nursing workload (NW) as a predictive factor of mortality by using the nursing activities score (NAS) scale. Materials and Methods: In this cross-sectional study of 91 days during 2019, convenience sampling was employed to recruit 82 registered nurses (RN) from three intensive care units (ICUs) of two public hospitals with 41 beds in total. Data were collected using the NAS scale, the researcher’s observation, the information given by the staff, and the nursing care reports. Descriptive and inductive statistics were used with significance level α = 0.05. The Statistical Package for Social Sciences (SPSS 25.0) was used for analyzing the data. Results: Females were the majority of the sample (84.1%), with a mean age of 38.9 (7.7) years, 87.8% had a nursing degree from a technological educational institute (T.E.I), the average working experience was 14 (8.1) years and the ICU experience was 12.9 (8.5) years. There were 3764 daily records of NAS with an average of 54.81 (2.34) and total NAS of 756.51 (150.27). The NW of the first day’s admission in the ICU was 65.15 (13.05), NW was 13.15 h/day and the NW of patients who died was 57.37 (4.06). The optimal nurse/patient ratio (NPR) was 1:1.82, while the existing NPR was 1:2.86. The mortality rate was 28.7%. Conclusion: Although the study results did not demonstrate a significant correlation between NW and mortality, the NW in ICU appeared to be relatively higher for patients who died than for those who survived. This result may serve as an indication for a positive correlation between these two variables. In addition, NW was found to be moderate, while one ICU nurse can take care of more than one patient.

The objective nursing workload and perceived nursing workload in Intensive Care Units: Analysis of association

BACKGROUND

A range of classification systems are in use for the measurement of nursing workload in Intensive Care Units. However, it is unknown to what extent the measured (objective) nursing workload, usually in terms of the amount of nursing activities, is related to the workload actually experienced (perceived) by nurses.

OBJECTIVES

The aim of this study was to assess the association between the objective nursing workload and the perceived nursing workload and to identify other factors associated with the perceived nursing workload.

METHODS

We measured the objective nursing workload with the Nursing Activities Score and the perceived nursing workload with the NASA-Task Load Index during 228 shifts in eight different Intensive Care Units. We used linear mixed-effect regression models to analyze the association between the objective and perceived nursing workload. Furthermore, we investigated the association of patient characteristics (severity of illness, comorbidities, age, body mass index, and planned or unplanned admission), education level of the nurse, and contextual factors (numbers of patients per nurse, the type of shift (day, evening, night) and day of admission or discharge) with perceived nursing workload. We adjusted for confounders.

RESULTS

We did not find a significant association between the observed workload per nurse and perceived nursing workload (p=0.06). The APACHE-IV Acute Physiology Score of a patient was significantly associated with the perceived nursing workload, also after adjustment for confounders (p=0.02). None of the other patient characteristics was significantly associated with perceived nursing workload. Being a certified nurse or a student nurse was the only nursing or contextual factor significantly associated with the perceived nursing workload, also after adjustment for confounders (p=0.03).

CONCLUSION

Workload is perceived differently by nurses compared to the objectively measured workload by the Nursing Activities Score. Both the severity of illness of the patient and being a student nurse are factors that increase the perceived nursing workload. To keep the workload of nurses in balance, planning nursing capacity should be based on the Nursing Activities Score, on the severity of patient illness and the graduation level of the nurse.

Impact of COVID-19 on nursing time in intensive care units in Belgium

INTRODUCTION

The COVID-19 pandemic has had a significant impact on nursing practice in intensive care unit and consequently, on workload.

OBJECTIVE

To assess the nurse-patient ratio required by COVID-19 patients and to identify the factors that influence nursing in this context.

DESIGN

This study was a retrospective observational study that evaluated the ratio using the Nursing Activities Score (NAS).

SETTING

Three Belgian French-speaking hospitals, including five ICUs. Patients included COVID-19 and non-COVID-19 patients.

MEASUREMENTS AND MAIN RESULTS

The study included 95 COVID-19 patients and 1604 non-COVID-19 patients (control group) resulting in 905 and 5453 NAS measures, respectively. The NAS was significantly higher among the COVID-19 patients than in the control group (p = <0.0001). In the COVID-19 group, these higher scores were also observed per shift and uniformly across the three hospitals. COVID-19 patients required more time in the activities of monitoring and titration (χ2 = 457.60, p = <0.0001), mobilisation (χ2 = 161.21, p = <0.0001), and hygiene (χ2 = 557.77, p = <0.0001). Factors influencing nursing time measured by NAS in the COVID-19 patients were age <65 years old (p = 0.23), the use of continuous venovenous hemofiltration (p = 0.002), a high APACHE II score (p = 0.006) and patient death (p = 0.002). A COVID-19 diagnosis was independently associated with an increase in nursing time (OR = 4.8, 95% CI:3.6-6.4).

CONCLUSIONS

Patients hospitalised in the ICU due to COVID-19 require significantly more nursing time and need an average ratio of almost 1:1.

Nursing workload in intensive care units and the influence of patient and nurse characteristics

BACKGROUND

Understanding factors that can potentially influence patient care and nursing workload in intensive care units is important. Previous studies have shown contradictory outcomes about the relationships between nursing workload and patient and nurse characteristics.

AIMS AND OBJECTIVES

This study aimed to investigate nursing workload in intensive care units and examine the association between this in relation to patient and nurse characteristics.

DESIGN

A cross-sectional design was conducted.

METHODS

All nurses who were working in the intensive care units of five hospitals and met the study criteria were enrolled in the study. Two demographic questionnaires collected nurse and patient demographic information. The Nursing Activities Score was applied to determine nursing workload in three shifts (morning, evening, night) for each nurse. Data were analysed using the independent sample t-test, one-way analysis of variance, and multivariable linear regression analysis.

RESULTS

The Nursing Activities Score was calculated for 509 patients who were under the care of 105 intensive care unit nurses. The mean (SD) Nursing Activities Score was 72.84% (22.07%). Morning shifts, male patients, medical treatments, and referred patients from the emergency ward and other intensive care units imposed a higher workload for nurses. Specifically, female nurses, increased number of patients receiving care, and increased patient length of intensive care unit stay were directly associated with increased Nursing Activities Scores. Work in surgical and burn intensive care units were inversely associated with the Nursing Activities Score.

CONCLUSION

This study suggests that the workload of nurses in intensive care units can be affected by both nurse and patient characteristics.

RELEVANCE TO CLINICAL PRACTICE

The findings can be used to ensure appropriate staffing of intensive care units by nurses. However, nurse and patient characteristics should not be considered the only factors that influence nursing workload in intensive care units.