Staffing and Organisation of Nursing Care in Cardiac Intensive Care Units in Greece

Intensive Care Nurses' Experience of Caring in Greece; A Qualitative Study

BACKGROUND

Whilst nurses and critical care services have been at the forefront of the COVID-19 pandemic, it has become more apparent that intensive care nurses are presented with challenging ethical and clinical decisions and are required to care for individuals with critical illnesses under high-pressure conditions. This is not a new phenomenon. The aim of this study, which was conducted before the outbreak of COVID-19, was to explore the experience of caring through the narratives of intensive care nurses in Greece.

METHODS

A qualitative study was conducted through in-depth, semi-structured interviews with nineteen ICU nurses in Athens. Transcripts were subjected to Braun and Clarke's thematic analysis and organised with Atlas.ti v8 QDA software.

RESULTS

The intensive care nurses' experience of caring in Greece encompassed four themes: (A) being "proximal", "co-present" and caring with empathy, (B) being "responsible" for your patient and negotiating with the doctors, (C) technology and "fighting with all you've got", and (D) "not being kept informed" and disappointment.

CONCLUSIONS

The narratives of this study highlight that ICU nurses in Greece provide patient-centred and compassionate care. Nurse leaders should develop appropriate healthcare policies so as to ensure the adequate provision of staff, specialist education, and support to nurses working in critical care. Failure to address these issues may lead to poor quality of care and negative patient outcomes.

Cardiovascular nurses' experiences of working in the COVID-19 intensive care unit: A qualitative study

BACKGROUND

Cardiovascular nurses' skills and experiences of cardiac critical care, management of cardiovascular emergencies, and mechanical circulatory support have been considered vital in providing nursing care for COVID-19 patients in intensive care units during the COVID-19 pandemic. To our knowledge, there are no studies have focused on the contribution and experiences of cardiovascular nurses in the critical care of COVID-19 patients.

OBJECTIVES

To explore the experiences of cardiovascular nurses working in a COVID-19 intensive care unit during the pandemic.

METHODS

The study was conducted as a qualitative study with phenomenological approach in June-December 2020. Study data were gathered from ten cardiovascular nurses through semi-structured interviews.

RESULTS

Six themes emerged from the interview data: the duties and responsibilities in a COVID-19 intensive care unit; the differences of COVID-19 intensive care unit practices from cardiovascular practices; the transferrable skills of cardiovascular nurses in a COVID-19 intensive care unit; the difficulties encountered working in a COVID-19 intensive care unit; the difficulty of working with personal protective equipment; and the psychosocial effects of working in a COVID-19 intensive care unit.

CONCLUSION

Cardiovascular nurses made an important contribution to the management of nursing services with their experiences and skills in the COVID-19 pandemic.

Continuous care and patients' basic needs during weaning from mechanical ventilation: A qualitative study

BACKGROUND

Mechanical ventilation is associated with a number of risks and complications. Thus, rapid and safe weaning from mechanical ventilation is of great importance. Weaning is a complex and challenging process, requiring continuous care and knowledge of the patient.

AIMS

The aim of the present study was to describe the continuous care process during weaning as well as to analyse the facilitators and obstacles to the weaning process from start to finish from the perspective of intensive care unit (ICU) staff, particularly nurses.

RESEARCH DESIGN

Twenty-two ICU staff members, including nurses and physicians, and three patients hospitalised in the ICU were enrolled in this qualitative study. Semi-structured interviews were used for data collection and the transcripts were analysed using qualitative content analysis.

FINDINGS

'Continuous care' was found to be the patients' basic need during weaning from mechanical ventilation. Uninterrupted, stable, comprehensive and dynamic care and monitoring with immediate response to all physiological and psychological changes were features of continuous care. The three main themes identified by this study were time spent with the patient, comprehensive supervision and maintenance of the quality of care during shifts.

CONCLUSION

Continuous and constant care should be provided during the weaning process. Such care will help to provide health care staff with a deeper understanding of the patient and his or her continuous changes, leading to a timely and favourable response during weaning. To achieve this goal, skill, communication and organisational changes are essential.

Difficult to wean patients: cultural factors and their impact on weaning decision-making

AIMS AND OBJECTIVES

To examine the elements of the intensive care environment and consider the impact on nurses' involvement in decision-making when weaning from mechanical ventilation.

BACKGROUND

Optimal management of difficult to wean patients requires the dynamic collaboration of all clinicians and the contribution of their knowledge and skills. The introduction of weaning protocols has increased nurses' input in decision-making, but there are various elements of the decision environment that impact on their involvement, which have been given little consideration.

DESIGN

Ethnography was used as the research design for this study.

METHODS

Fieldwork took place in two tertiary hospitals in Greece and Scotland for five months each to unveil clinicians' behaviour and interactions during the weaning practice. Observation was based on the weaning process of 10 Scottish and 9 Greek long-term ventilated patients. Semi-structured interviews followed with nurses (n = 33) and doctors (n = 9) in both settings to understand nurses' perceived involvement in weaning decision-making. Thematic analysis of interviews and field notes followed using the Qualitative Data Analysis software NVivo. Clinicians' participation was voluntary.

RESULTS

The main themes identified were the (1) organisation of the units (time and structure of the ward rounds, staff levels and staff allocation system), (2) the inter- professional relationships, (3) the ownership and accountability in weaning decision-making and (4) the role of the weaning protocols. These elements described the culture of the ICUs and defined nurses' role in weaning decision-making.

CONCLUSIONS

Clinical decision-making is a multi-dynamic process specifically in complex clinical situations such as weaning from mechanical ventilation. This paper suggests that weaning practice should be considered in relation to the elements of the clinical environment to provide an individualised and patient-centred weaning approach.

RELEVANCE TO CLINICAL PRACTICE

Methods to enhance nurses' role in teamwork and collaborative decision-making are suggested.

Job satisfaction and work related variables in Chinese cardiac critical care nurses

AIM

To explore critical care nurses' views of their job satisfaction and the relationship with job burnout, practice environment, coping style, social support, intention to stay in current employment and other work-related variables.

BACKGROUND

Nurse shortage is a global issue, especially in critical care. Job satisfaction is the most frequently cited factor linked to nurses' turnover.

METHOD

A convenience sample of cardiac critical care nurses (n = 215; 97.7% response rate) from 12 large general hospitals in Shanghai was surveyed from December 2010 to March 2011.

RESULT

Over half of the sample reported satisfaction with their jobs. Nurses with 10-20 years of professional experience and those who had taken all their holiday entitlement reported higher levels of job satisfaction. The independent variables of practice environment, intention to stay, emotional exhaustion, personal accomplishment and positive coping style explained about 55% of the variance in job satisfaction.

CONCLUSION

Chinese cardiac critical care nurses' job satisfaction was related to work related variables, which are amenable to managerial action.

IMPLICATIONS FOR NURSING MANAGEMENT

Our findings highlight the imperative of improving intrinsic and extrinsic rewards, together with the flexibility of work schedules to promote job satisfaction and staff retention. A clinical ladder system is needed to provide promotion opportunities for Chinese nurses.

Crucial information needs of ICU charge nurses in Finland and Greece

AIMS

To describe crucial information needs of ICU charge nurses, and to compare these needs in two countries in Europe.

BACKGROUND

ICU charge nurses are on the front line for ensuring that the activities of their units are running smoothly. They are accountable for making sure that the right tasks are performed under the right circumstances, with the right people, at the right time.

DESIGN AND PARTICIPANTS

An online survey based on a previous observation study regarding the ad hoc decision-making of ICU shift leaders. A total of 257 Finnish and 50 Greek ICU charge nurses participated in this study, from 17 Finnish and 16 Greece ICUs for adults.

METHODS

Our survey incorporated 122 statements divided into six dimensions (patient admission, organization and management of work, allocation of staff, allocation of material, special treatments and patient discharge) with a rating scale from 0 to 10. Analysis involved descriptive statistics. Mann-Whitney U and Kruskal-Wallis tests were used to compare the answers of the two countries. Validity was verified with confirmatory factor analysis and the reliability was tested with Cronbach's α values.

RESULTS

The most crucial information needs of ICU charge nurses concerned the overall organization and management of work. Both staff-related and individual patient-related information was needed. Information needs of Finnish and Greek charge nurses concerned similar kinds of situations in ICUs. However, there were some differences that might depend on the cultural differences between the countries.

CONCLUSIONS

Accurate and real-time information is a prerequisite for ICU charge nurses' ad hoc decision-making during daily care management. Identification of the most crucial information is needed when tools for information management are developed.

RELEVANCE TO CLINICAL PRACTICE

The results of this study indicated that a major portion of immediate information needs of ICU charge nurses are internationally common in similar settings.

Professional autonomy and job satisfaction: survey of critical care nurses in mainland Greece

AIM

This paper is a report of a study conducted to describe Greek critical care nurses' views on professional autonomy and its relationship with job satisfaction and other work-related variables.

BACKGROUND

Professional autonomy is generally considered a highly desirable nursing attribute and a major factor in nurse job satisfaction. In the critical care environment, a high level of accountability, responsibility and autonomy are required to optimize outcomes of critically unstable patients.

METHOD

A questionnaire survey was conducted with a convenience sample of Greek critical care nurses (n = 431; response rate 70%) in 2007. Data were collected on professional autonomy, job satisfaction, role conflict and role ambiguity.

RESULTS

Overall, nurses reported acting moderately autonomously. Younger nurses reported statistically significant lower levels of autonomy. Higher levels of autonomy were reported by female nurses. Multiple logistic regression revealed that appointment level, type of critical care unit and registration with a professional organization were independently associated with autonomy. A positive moderate association was found between reported autonomy, job satisfaction, role conflict and role ambiguity, but there was no relationship between job satisfaction and reported role conflict and role ambiguity.

CONCLUSION

Further education, role enhancement and support are required for nurses working in critical care in Greece if they are to achieve the maximum potential of their professional role. Failure to address the perceptions of professional autonomy may have an impact on staff retention, because of job dissatisfaction.

Clinical and procedural predictors of nurse workload during and after invasive coronary procedures: the potential benefit of a systematic radial access

BACKGROUND

Invasive coronary procedures are increasing in number and complexity over time. This trend translates in an increased need for economical and human resources, among which is nurse staffing the most affected.

AIMS

To identify possible predictors of nurse workload, during and after diagnostic and interventional procedures.

METHODS

Two hundred and sixty consecutive patients were included: 52 and 208 patients underwent femoral and radial access, respectively. Nurse workload was calculated with a self-developed model.

RESULTS

Cathlab nurse workload was 103 [63--156] min. Independent predictors of increased Cathlab nurse workload were: femoral access, failed radial access and cross-over, interventional procedures, procedural time, urgent procedures. Cathlab nurse workload was 174 [134--218] and 86 [58--126] min, for femoral and radial access, respectively (p<0.001). Among the overall population, 174/260 patients (44 females, mean age 66+/-11 years) were hospitalised at our Center after the procedure. Fifty-six and 118 patients had femoral and radial access, respectively. Ward nurse workload was 457 [226--954] min. Independent predictors of increased Ward nurse workload were: access-site complication, length of in-hospital stay, admission to CCU, interventional procedures. Ward nurse workload was 386 [226--652] and 720 [314--1375] min, respectively for radial and femoral access (p<0.001).

CONCLUSIONS

A systematic radial access is an effective strategy for reducing nurse workload, both during, by simplifying nurse tasks in the CathLab, and after coronary invasive procedures, by preventing access-site complications, shortening in-hospital stays, and reducing admissions to CCU.

Recommendations for the structure, organization, and operation of intensive cardiac care units

Two major changes in patient characteristics and management occurred recently that demand distinctive alterations in the function of the intensive cardiac care unit (ICCU). These changes include the introduction of an early invasive strategy for the treatment of acute coronary syndromes, enabling early recuperation and shorter need for intensive care on the one hand, while the number of older and sicker patients requiring prolonged and more complex intensive care is steadily increasing. A task force of the European Society of Cardiology Working Group on Acute Cardiac Care was set to give a modern updated comprehensive recommendations concerning the structure, organization, and function of the modern ICCUs and intermediate cardiac units. These include the statement that specially trained cardiologists and cardiac nurses who can manage patients with acute cardiac conditions should staff the ICCUs. The optimum number of physicians, nurses, and other personal working in the unit is included. The document indicates the desired architecture and structure of the units and the intermediate cardiac unit and their relations to the other facilities in the hospital. Specific recommendations are also included for the minimal number of beds, monitoring system, respirators, pacemaker/defibrillators, and necessary additional equipment. The desired function is discussed, namely, the patients to be admitted, the length of stay, and the relocation policy. A uniformed electronic chart for ICCUs is advised, anticipating a common European database.

Effect of closed unit policy and appointing an intensivist in a developing country

OBJECTIVE

We hypothesized that a dual strategy--instituting a closed intensive care unit (ICU) policy and simultaneously appointing an intensivist--would improve patient outcome in a university hospital of a developing country and that the benefit would increase over time.

DESIGN

Data were prospectively collected over 5 months before the policy change (open policy) and over an initial 6 mos (early closed policy) and subsequent 12 mos (late closed policy) after the policy change.

SETTING

The study was conducted at a medical ICU of a university hospital in Turkey.

PATIENTS

Two hundred patients were recruited during open policy, 149 during early closed policy, and 210 during late closed policy.

MEASUREMENTS AND RESULTS

Instituting a closed policy and simultaneously appointing a critical care specialist was associated with the admission of sicker patients and more frequent use of invasive procedures. Compared with open policy, patients were approximately 4.5 times more likely to survive their hospital stay during early closed policy (p < .001) and approximately five times more likely during late closed policy (p < .0001). Among patients receiving mechanical ventilation, hospital mortality was lower during the early (57%) and late closed periods (59%) than during open period (91%; p < .01). In multivariate analysis, open policy, mechanical ventilation, central venous catheterization, sepsis, and higher Acute Physiology and Chronic Health Evaluation II score each independently predicted mortality. The change in policy resulted in the admission of progressively sicker patients over time and increased the use of mechanical ventilation and central venous catheters.

CONCLUSION

A dual strategy of closed policy and simultaneously appointing an intensivist fostered admission of sicker patients and improved the survival of patients requiring admission to an ICU of a developing country.

Practice and clinical decision-making autonomy among Hellenic critical care nurses

BACKGROUND

Nursing autonomy has been associated with better patient-outcomes; therefore, it is a priority for critical care nursing management. Low authority has been a persistent complaint of Hellenic intensive care unit nurses; however, issues of nursing autonomy have not been previously addressed empirically in Hellas.

PURPOSE

To investigate: (1) the perceived contribution to clinical decision-making, (2) the degree of autonomy in technical tasks, and (3) factors related to practice autonomy in critical care nurses in Hellas. Additionally, because of the lack of sufficient tools, this study also aimed to construct and to validate a new tool for assessing practice and clinical decision-making autonomy among Hellenic intensive care unit nurses.

MATERIALS AND METHODS

A Hellenic intensive care nursing autonomy scale, focused on technical aspects of care, was developed through literature review, a panel of experts and a pilot study in a random sample of 120 respondents. Items were refined by factor analysis, which revealed three major conceptual categories of autonomy: (1) basic technical, (2) advanced technical, and (3) clinical decision. Hellenic intensive care nursing autonomy (Likert 4, range: 38-152), was distributed to all nurses employed in intensive care units in Hellas (n = 807; attrition: 27%). Comparisons, correlation and multivariate regression were employed.

RESULTS

The Hellenic intensive care nursing autonomy scale exhibited appropriate reliability (Cronbach's alpha = 0.86) and validity properties. Autonomy scores were moderate (mean: 105.24 +/- 9.58). Highest autonomy was attributed to basic technical tasks, followed by advanced technical tasks and decision-making. Male gender and higher education were predictors of higher overall, advanced technical and decision-making autonomy (P = 0.01). Bachelor degree graduates scored higher in decisional autonomy (P = 0.03). Intensive care unit experience and type of intensive care unit were also important determinants of decisional autonomy (P = 0.02).

CONCLUSIONS

The results revealed moderate autonomy in technical tasks and low decisional autonomy among Hellenic intensive care unit nurses. Factors related to the educational preparation of nurses, gender issues and institutional characteristics might hinder intensive care unit nurses' autonomy in Hellas.