The work of adult and pediatric intensive care unit nurses

Standard practices in cardiac monitoring: training needs of intensive care unit nurses

BACKGROUND

Enforcing practice standards for cardiac monitoring in intensive care units (ICUs) has been shown to reduce misdiagnoses and inappropriate interventions. Continuous professional development (CPD) programs are committed to aligning clinical practices with recommended standards. The crucial initial phase in CPD development involves assessing the training needs of the targeted population.

OBJECTIVE

To assess the training needs of ICU nurses in cardiac monitoring. The overarching goal was to formulate a focused Continuous Professional Development (CPD) program geared towards implementing standard practices in cardiac monitoring.

METHODS

This study employed a generic qualitative approach with a descriptive design, utilizing interviews and focus groups from July to September 2018. Involving 16 ICU nurses. Content analysis was employed, encompassing transcription, fluctuant and iterative reading, unitization, categorization, coding, description, and interpretation.

RESULTS

All nurses recognized cardiac monitoring's importance in the ICU but reported barriers to its effective implementation which were related to factors that could addressed by a CPD as insufficient knowledge and skills. Training needs were identified in both clinical and technical aspects, with recommendations for practical and theoretical activities and e-learning strategies. Barriers related to organizational aspects (equipment and communication within the healthcare team) were also mentioned.

CONCLUSION

ICU nurses presented clear and specific training needs related to cardiac monitoring as knowledge, skills, and competencies. Other organizational aspects were also reported as barriers. Addressing these learning needs through targeted CPD aligned with organizational initiatives can contribute to enhancing the quality of cardiac monitoring practices in ICUs.

Algorithmic prediction of anaesthesia manpower quantity needs: A multicentre study

BACKGROUND

A shortage of anaesthetists affects health system globally. This is a study on task-force to develop a predictive model for the appropriate number of anaesthetic providers (Y).

METHODS

A cross-sectional study was performed with randomisation from every health service region across Thailand. The decision-making criteria for manpower needed were written and provided guidance. The number of personnel was calculated from the sum of total time spent by all anaesthetic providers divided by duration of the service. Linear regression analysis was applied.

RESULTS

In total 3774 patients were included from 18 hospitals. The factors that affect the anaesthetic providers' allocation needs were included in the predictive model, calculated as Y = 3.53 + [0.56 (standard centre) + 0.36 (advanced centre) + 1.03 (specialty centre)] + 0.07 (American Society of Anesthesiologists physical status IV and V) + 0.61 (advanced anaesthetic medication) + [0.61 (monitored anaesthesia care) + 0.17 (general anaesthesia)] - [0.27 (pre-anaesthetic duration within 31-60 minutes) + (0.61 (over 60 minutes)] - [0.85 (anaesthetic duration within 31-60 minutes) + 1.04 (within 61-120 minutes) + 1.32 (over 120 minutes)] - [0.16 (post-anaesthetic duration within 31-60 minutes) + 0.45 (within 61-90 minutes) + 0.74 (over 90 minutes)].

CONCLUSION

The anaesthesia manpower algorithm developed during this study can be used to calculate the number of anaesthetists per population to maintain health services.

Getting to health equity in NICU care in the USA and beyond

Differences in race/ethnicity, gender, income and other social factors have long been associated with disparities in health, illness and premature death. Although the terms 'health differences' and 'health disparities' are often used interchangeably, health disparities has recently been reserved to describe worse health in socially disadvantaged populations, particularly members of disadvantaged racial/ethnic groups and the poor within a racial/ethnic group. Infants receiving disparate care based on race/ethnicity, immigration status, language proficiency, or social class may be discomforting to healthcare workers who dedicate their lives to care for these patients. Recent literature, however, has documented differences in neonatal intensive care unit (NICU) care quality that have contributed to racial and ethnic differences in mortality and significant morbidity. We examine the within-NICU and between-NICU mechanisms of disparate care and recommend approaches to address these disparities.

Impact of Pediatric Intensive Care Unit Preadmission Huddle on Perceptions of Interprofessional Communication About Patient Safety

BACKGROUND

Preadmission discussions in the study institution's pediatric intensive care unit are not standardized and admission plans were thought to be disjointed, leading to a perceived lack of organization and preparation for the arrival of a critically ill child.

OBJECTIVE

To evaluate the impact of a new, formalized preadmission pediatric intensive care unit interdisciplinary huddle on clinician perceptions of interprofessional communication. The hypothesis was that preadmission huddles would improve unit clinicians' perceptions of interprofessional communication.

METHODS

Interprofessional pediatric intensive care unit clinicians (physicians, advanced practice providers, nurses, and respiratory therapists) completed surveys before and 7 months after preadmission interdisciplinary huddle implementation. Huddle compliance and perceptions of interprofessional communication in the unit were evaluated.

RESULTS

Of 265 eligible pediatric intensive care unit admissions, 69 huddles (26.0%) occurred. The postintervention survey revealed increased odds (odds ratio [95% CI]) of responding "strongly agree" or "agree" to questions about the opportunity to "communicate effectively with health care team members" (2.42 [1.10-5.34]), "respond to feedback from health care team members" (2.54 [1.23-5.24]), and "convey knowledge to other health care team members" (2.71 [1.31-5.61]) before an admission.

DISCUSSION

This study introduced a formalized huddle that improved pediatric intensive care unit clinicians' perceived communication with other health care team members in the preadmission period.

CONCLUSIONS

Future studies are needed to determine if this perceived improvement in communication significantly affects health care outcomes of critically ill children or if these results are generalizable to other pediatric intensive care unit settings.

Intensive care nurses' experiences using volatile anaesthetics in the intensive care unit: An exploratory study

OBJECTIVE

To explore the experiences intensive care nurses have with volatile anaesthetics in the intensive care unit.

RESEARCH METHODOLOGY AND DESIGN

A qualitative exploratory and descriptive design was used. Data were collected in 2019 from individual interviews with nine intensive care nurses, who were recruited using purposive sampling. Data were analysed using systematic text condensation.

SETTING

The study was undertaken in two general intensive care units from different university hospitals in Norway where volatile anaesthetics were utilised.

FINDINGS

Three categories emerged from the data analysis: experiencing the benefits of volatile anaesthetics; coping with unfamiliarity in handling volatile anaesthetics; and meeting challenges related to volatile anaesthetics in practice.

CONCLUSION

The intensive care nurses had positive experiences related to administering volatile anaesthetics in the intensive care unit and responded positively to the prospect of using it more often. Because volatile anaesthetics were rarely used in their units, the participants felt uncertain regarding its use due to unfamiliarity. Collegial support and guidelines were perceived as pivotal in helping them cope with this uncertainty. The participants also experienced several challenges in using volatile anaesthetics in the intensive care unit, with ambient pollution being regarded as the main challenge.

Job performance in healthcare: a systematic review

BACKGROUND

Healthcare organisations face major challenges to keep healthcare accessible and affordable. This requires them to transform and improve their performance. To do so, organisations must influence employee job performance. Therefore, it is necessary to know what the key dimensions of job performance in healthcare are and how these dimensions can be improved. This study has three aims. The first aim is to determine what key dimensions of job performance are discussed in the healthcare literature. The second aim is to determine to which professionals and healthcare organisations these dimensions of job performance pertain. The third aim is to identify factors that organisations can use to affect the dimensions of job performance in healthcare.

METHODS

A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The authors searched Scopus, Web of Science, PubMed, and Google Books, which resulted in the identification of 763 records. After screening 92 articles were included.

RESULTS

The dimensions - task, contextual, and adaptative performance and counterproductive work behaviour - are reflected in the literature on job performance in healthcare. Adaptive performance and counterproductive work behaviour appear to be under-researched. The studies were conducted in different healthcare organisations and pertain to a variety of healthcare professionals. Organisations can affect job performance on the macro-, meso-, and micro-level to achieve transformation and improvement.

CONCLUSION

Based on more than 90 studies published in over 70 journals, the authors conclude that job performance in healthcare can be conceptualised into four dimensions: task, contextual and adaptive performance, and counterproductive work behaviour. Generally, these dimensions correspond with the dimensions discussed in the job performance literature. This implies that these dimensions can be used for further research into job performance in healthcare. Many healthcare studies on job performance focus on two dimensions: task and contextual performance. However, adaptive performance, which is of great importance in constantly changing environments, is under-researched and should be examined further in future research. This also applies to counterproductive work behaviour. To improve job performance, interventions are required on the macro-, meso-, and micro-levels, which relate to governance, leadership, and individual skills and characteristics.

Healthcare workers' structured daily reflection on patient safety, workload and work environment in intensive care. A descriptive retrospective study

OBJECTIVES

To describe the results of use of structured daily reflection assessments among healthcare workers at an intensive care unit over the course of one year.

METHODS

In this descriptive retrospective study, data were analysed both quantitatively and qualitatively. The data encompassed 1095 work shifts, evaluated by healthcare workers at an intensive care unit using a structured daily reflection instrument. The areas evaluated were patient safety, workload and work environment, and free-text comments were possible.

FINDINGS

The results showed that 36% (n = 395) of work shifts, most of them daytime shifts (44%; n = 161), were affected. Workload was the area that affected most work shifts (29%; n = 309). Missed nursing care, complex care and inaccurate communication impacted patient safety, while patient care, multitasking and working conditions affected workload. Work environment was impacted by organisational factors, environment, lack of control and moral stress.

CONCLUSION

Using daily reflection among healthcare workers in the intensive care unit illuminated areas that affect patient safety, workload, and work environment. The importance of communication and collaboration and how they can impact patient safety, workload, and the work environment were highlighted by the team.

Registered nurses' experiences of working in the intensive care unit during the COVID-19 pandemic

Background

During the pandemic, increased numbers of patients requiring intensive care unit (ICU) admission required an increase in ICU capacity, including ICU staffing with competence to care for critically ill patients. Consequently, nurses from acute care areas were called in to staff the ICU along with experienced intensive care nurses.

Aims and objectives

To describe Swedish registered nurses' experiences of caring for patients with COVID‐19 in ICUs during the pandemic.

Design

Mixed method survey design.

Methods

An online questionnaire was distributed through social media to registered nurses who had been working in the ICU during the COVID‐19 outbreak. Data were collected for 1 week (May 2020) and analysed using content analysis and descriptive statistics.

Results

Of the 282 nurses who participated, the majority were ICU nurses (n = 151; 54%). Half of the nurses specialized in ICU reported that they were responsible for the ICU care of three or more patients during the pandemic (n = 75; 50%). Among non‐intensive care nurses, only 19% received introduction to the COVID‐19 ICU (n = 26). The analysis of data regarding nurses' experiences resulted in three categories: tumbling into chaos, diminished nursing care, and transition into pandemic ICU care. Participants described how patient safety and care quality were compromised, and that nursing care was severely deprioritized during the pandemic. The situation of not being able to provide nursing care resulted in ethical stress. Furthermore, an increased workload and worsened work environment affected nurses' health and well‐being.

Conclusions

The findings from the present study indicate that nurses perceived that patient safety and quality of care were compromised during the pandemic. This resulted in ethical stress among nurses, which may have affected their physical and psychosocial well‐being.

Relevance to clinical practice

The COVID‐19 pandemic had a severe impact on nurses' work environment, which could result in burnout and staff turnover.

Reduction of phone interruptions post implementation of a central call center in community pharmacies of an academic health system

PURPOSE

A pharmacy services call center (PSCC) was implemented to centralize pharmacy phone calls and reduce interruptions of dispensing activities in 7 community pharmacies of an academic health center. An evaluation was conducted to define, quantify, and compare the numbers and types of phone interruptions before and 3 months after PSCC implementation.

METHODS

Through structured, direct observation of pharmacy staff, the numbers and types of "breaks in task" (BIT) due to phone interruptions and other distractions were identified. A standardized data collection tool formatted on tablet computers was used by trained observers to document BIT for 3-hour time blocks on 5 consecutive business days (2 days of pharmacist observation and 3 days of technician observation, for a total of 10 observation days per pharmacy).

RESULTS

Over 5,000 prescriptions were processed during 414 hours of observation (13.3 prescriptions per observation hour). Overall, BIT due to phone interruptions totaled 2.2 BIT per observation hour, with those interruptions reduced by 46.4% overall after PSCC implementation (by 30.0% in 4 small pharmacies and by 57.5% in 3 large pharmacies). Technicians were more likely than pharmacists to be interrupted by phone vs nonphone BIT (eg, distraction by another technician, pharmacist, or patient). Comparison of phone vs nonphone BIT suggested an overall 46.0% reduction in phone BIT in all pharmacies (reductions of 42.4% and 45.0% in large and small pharmacies, respectively).

CONCLUSION

PSCC implementation noticeably decreased the amount of phone interruptions and distractions for employees.

Time and quality of admissions: nursing workload

OBJECTIVES

to measure the average time spent by the nursing staff during patient admission and investigate their compliance with the activities described by the Nursing Interventions Classification; evaluate the degree of interference in the workload of the team.

METHODS

observational with time measurement through software. We followed 199 admissions made by the nursing staff in seven units, using two validated instruments. Total scores ≥ 70% and 50% validated the process.

RESULTS

the average time of nurses ranged from 5.5 (standard deviation = 2.3) to 13 (standard deviation = 1.1) minutes; and the auxiliary / technician, between 4.7 (standard deviation = 2.1) and 6.8 (standard deviation = 2.0) minutes (p ≤ 0.01). We qualified six admissions made by nurses and 33 by assistants/technicians. The intervention spent 16.3% to 31.5% of the working hours of the team.

CONCLUSIONS

admission impacts nursing workload and needs to be considered both in the measurement of activities and in the sizing of the nursing staff.

Development and use of an adjusted nurse staffing metric in the neonatal intensive care unit

OBJECTIVE

To develop a nurse staffing prediction model and evaluate deviation from predicted nurse staffing as a contributor to patient outcomes.

DATA SOURCES

Secondary data collection conducted 2017-2018, using the California Office of Statewide Health Planning and Development and the California Perinatal Quality Care Collaborative databases. We included 276 054 infants born 2008-2016 and cared for in 99 California neonatal intensive care units (NICUs).

STUDY DESIGN

Repeated-measures observational study. We developed a nurse staffing prediction model using machine learning and hierarchical linear regression and then quantified deviation from predicted nurse staffing in relation to health care-associated infections, length of stay, and mortality using hierarchical logistic and linear regression.

DATA COLLECTION METHODS

We linked NICU-level nurse staffing and organizational data to patient-level risk factors and outcomes using unique identifiers for NICUs and patients.

PRINCIPAL FINDINGS

An 11-factor prediction model explained 35 percent of the nurse staffing variation among NICUs. Higher-than-predicted nurse staffing was associated with decreased risk-adjusted odds of health care-associated infection (OR: 0.79, 95% CI: 0.63-0.98), but not with length of stay or mortality.

CONCLUSIONS

Organizational and patient factors explain much of the variation in nurse staffing. Higher-than-predicted nurse staffing was associated with fewer infections. Prospective studies are needed to determine causality and to quantify the impact of staffing reforms on health outcomes.

Identifying Barriers to Nurse-Facilitated Patient Mobility in the Intensive Care Unit

BACKGROUND

Nurse-facilitated mobility of patients in the intensive care unit can improve outcomes. However, a gap exists between research findings and their implementation as part of routine clinical practice. Such a gap is often attributed, in part, to the barrier of lack of time. The Translating Evidence Into Practice model provides a framework for research implementation, including recommendations for identifying barriers to implementation via direct observation of clinical care.

OBJECTIVES

To report on design, implementation, and outcomes of an approach to identify and understand lack of time as a barrier to nurse-facilitated mobility in the intensive care unit.

METHODS

An interprofessional team designed the observational process and evaluated the resulting data by using qualitative content analysis.

RESULTS

During three 4-hour observations of 2 nurses and 1 nursing technician, 194 distinct tasks were performed (ie, events). A total of 4 categories of nurses' work were identified: patient care (47% of observation time), provider communication (25%), documentation (18%), and down time (10%). In addition, 3 types of potential mobility events were identified: in bed, edge of bed, and out of bed. The 194 observed events included 34 instances (18%) of potential mobility events that could be implemented: in bed (53%), edge of bed (6%), and out of bed (41%).

CONCLUSIONS

Nurses have limited time for additional clinical activities but may miss potentially important opportunities for facilitating patient mobility during existing patient care. The proposed method is feasible and helpful in empirically investigating barriers to nurse-facilitated patient mobility in the intensive care unit.

Understanding Nursing Workflow for Inpatient Education Delivery: Time and Motion Study

Background

Diabetes self-management education and support improves diabetes-related outcomes, but many persons living with diabetes do not receive this. Adults with diabetes have high hospitalization rates, so hospital stays may present an opportunity for diabetes education. Nurses, supported by patient care technicians, are typically responsible for delivering patient education but often do not have time. Using technology to support education delivery in the hospital is one potentially important solution.

Objective

The aim of this study was to evaluate nurse and patient care technician workflow to identify opportunities for providing education. The results informed implementation of a diabetes education program on a tablet computer in the hospital setting within existing nursing workflow with existing staff.

Methods

We conducted a time and motion study of nurses and patient care technicians on three medical-surgical units of a large urban tertiary care hospital. Five trained observers conducted observations in 2-hour blocks. During each observation, a single observer observed a single nurse or patient care technician and recorded the tasks, locations, and their durations using a Web-based time and motion data collection tool. Percentage of time spent on a task and in a location and mean duration of task and location sessions were calculated. In addition, the number of tasks and locations per hour, number of patient rooms visited per hour, and mean time between visits to a given patient room were determined.

Results

Nurses spent approximately one-third of their time in direct patient care and much of their time (60%) on the unit but not in a patient room. Compared with nurses, patient care technicians spent a significantly greater percentage of time in direct patient care (42%; P=.001). Nurses averaged 16.2 tasks per hour, while patient care technicians averaged 18.2. The mean length of a direct patient care session was 3:42 minutes for nurses and 3:02 minutes for patient care technicians. For nurses, 56% of task durations were 2 minutes or less, and 38% were one minute or less. For patient care technicians, 62% were 2 minutes or less, and 44% were 1 minute or less. Nurses visited 5.3 and patient care technicians 9.4 patient rooms per hour. The mean time between visits to a given room was 37:15 minutes for nurses and 33:28 minutes for patient care technicians.

Conclusions

The workflow of nurses and patient care technicians, constantly in and out of patient rooms, suggests an opportunity for delivering a tablet to the patient bedside. The average time between visits to a given room is consistent with bringing the tablet to a patient in one visit and retrieving it at the next. However, the relatively short duration of direct patient care sessions could potentially limit the ability of nurses and patient care technicians to spend much time with each patient on instruction in the technology platform or the content.

Describing drug and fluid therapy in the paediatric intensive care unit: A pilot study

PURPOSE

Care in the paediatric intensive care unit (PICU) involves many clinical activities. The objectives of this study were to evaluate the feasibility of a novel observation method, the reliability of data abstraction, and to report the initial findings from application of this approach.

MATERIALS AND METHODS

Bedside activities of patients and clinical staff were recorded by direct observational study using video recording and audio annotation. Data were abstracted into 9 broad clinical activities and 12 specific drug-fluid activities. Enrolment rates, agreement between abstractors, clinical activity durations and interruptions are reported.

RESULTS

We enrolled 42 healthcare professionals, 12 family members of 13 patients, and recorded 12 patients (consent rates of 70%-92%). There were 884 clinical activity episodes. Each hour was comprised of a median (IQR) of 11.9 (4.8-16.5) minutes of drug and fluid related tasks. The 682 drug and fluid related activities were mainly preparation and administration. Interruptions occurred on average 7 times per hour. Data abstraction for 8 h had intra-class correlation co-efficient (95% CI) of 0.91 (079-0.96).

CONCLUSIONS

Real-time recording of clinical tasks in the PICU using a direct observation model combined with video recording is feasible. Preliminary results suggest abundant and diverse activity is routine.

Sensor-based measurement of critical care nursing workload: Unobtrusive measures of nursing activity complement traditional task and patient level indicators of workload to predict perceived exertion

OBJECTIVE

To establish the validity of sensor-based measures of work processes for predicting perceived mental and physical exertion of critical care nurses.

MATERIALS AND METHODS

Repeated measures mixed-methods study in a surgical intensive care unit. Wearable and environmental sensors captured work process data. Nurses rated their mental (ME) and physical exertion (PE) for each four-hour block, and recorded patient and staffing-level workload factors. Shift was the grouping variable in multilevel modeling where sensor-based measures were used to predict nursing perceptions of exertion.

RESULTS

There were 356 work hours from 89 four-hour shift segments across 35 bedside nursing shifts. In final models, sensor-based data accounted for 73% of between-shift, and 5% of within-shift variance in ME; and 55% of between-shift, and 55% of within-shift variance in PE. Significant predictors of ME were patient room noise (ß = 0.30, p < .01), the interaction between time spent and activity levels outside main work areas (ß = 2.24, p < .01), and the interaction between the number of patients on an insulin drip and the burstiness of speaking (ß = 0.19, p < .05). Significant predictors of PE were environmental service area noise (ß = 0.18, p < .05), and interactions between: entropy and burstiness of physical transitions (ß = 0.22, p < .01), time speaking outside main work areas and time at nursing stations (ß = 0.37, p < .001), service area noise and time walking in patient rooms (ß = -0.19, p < .05), and average patient load and nursing station speaking volume (ß = 0.30, p < .05).

DISCUSSION

Analysis yielded highly predictive models of critical care nursing workload that generated insights into workflow and work design. Future work should focus on tighter connections to psychometric test development methods and expansion to a broader variety of settings and professional roles.

CONCLUSIONS

Sensor-based measures are predictive of perceived exertion, and are viable complements to traditional task demand measures of workload.

ICU nurses and physicians dialogue regarding patients clinical status and care options-a focus group study

Nurses and physicians work side-by-side in the intensive care unit (ICU). Effective exchanges of patient information are essential to safe patient care in the ICU. Nurses often rate nurse-physician communication lower than physicians and report that it is difficult to speak up, that disagreements are not resolved and that their input is not well received. Therefore, this study explored nurses' dialogue with physicians regarding patients' clinical status and the prerequisites for effective and accurate exchanges of information. We adopted a qualitative approach, conducting three focus group discussions with five to six nurses and physicians each (14 total). Two themes emerged. The first theme highlighted nurses' contributions to dialogues with physicians; nurses' ongoing observations of patients were essential to patient care discussions. The second theme addressed the prerequisites of accurate and effective dialogue regarding care options, comprising three subthemes: nurses' ability to speak up and present clinical changes, establishment of shared goal and clinical understanding, and open dialogue and willingness to listen to each other. Nurses should understand their essential role in conducting ongoing observations of patients and their right to be included in care-related decision-making processes. Physicians should be willing to listen to and include nurses' clinical observations and concerns.

Facilitated Nurse Medication-Related Event Reporting to Improve Medication Management Quality and Safety in Intensive Care Units

BACKGROUND

Medication safety presents an ongoing challenge for nurses working in complex, fast-paced, intensive care unit (ICU) environments. Studying ICU nurse's medication management-especially medication-related events (MREs)-provides an approach to analyze and improve medication safety and quality.

OBJECTIVES

The goal of this study was to explore the utility of facilitated MRE reporting in identifying system deficiencies and the relationship between MREs and nurses' work in the ICUs.

METHODS

We conducted 124 structured 4-hour observations of nurses in three different ICUs. Each observation included measurement of nurse's moment-to-moment activity and self-reports of workload and negative mood. The observer then obtained MRE reports from the nurse using a structured tool. The MREs were analyzed by three experts.

RESULTS

MREs were reported in 35% of observations. The 60 total MREs included four medication errors and seven adverse drug events. Of the 49 remaining MREs, 65% were associated with negative patient impact. Task/process deficiencies were the most common contributory factor for MREs. MRE occurrence was correlated with increased total task volume. MREs also correlated with increased workload, especially during night shifts.

DISCUSSION

Most of these MREs would not be captured by traditional event reporting systems. Facilitated MRE reporting provides a robust information source about potential breakdowns in medication management safety and opportunities for system improvement.

Hospital Nurses' Work Activity in a Technology-Rich Environment: A Triangulated Quality Improvement Assessment

The aim of this project was to describe hospital nurses' work activity through observations, nurses' perceptions of time spent on tasks, and electronic health record time stamps. Nurses' attitudes toward technology and patients' perceptions and satisfaction with nurses' time at the bedside were also examined. Activities most frequently observed included documenting in and reviewing the electronic health record. Nurses' perceptions of time differed significantly from observations, and most patients rated their satisfaction with nursing time as excellent or good.

Intrahospital transfers and the impact on nursing workload

AIMS AND OBJECTIVES

To determine the rate of patient moves and the impact on nurses' time.

BACKGROUND

Bed shortages and strategies designed to increase patient flow have led to a global increase in patient transfers between wards. The impact of transferring patients between wards and between beds within a ward on nurses' workload has not previously been measured.

DESIGN

A two-stage sequential study. Retrospective analysis of hospital data and a prospective observational-timing study.

METHODS

Secondary analysis of an administrative data set to inform the rate of ward and bed transfers (n = 34,715) was undertaken followed by an observational-timing study of nurses' activities associated with patient transfers (n = 75).

RESULTS

Over 10,000 patients were moved 34,715 times in 1 year which equates to an average of 2.4 transfers per patient. On average, patient transfers took 42 min and bed transfers took 11 min of nurses' time. Based on the frequency of patient moves, 11.3 full-time equivalent nurses are needed to move patients within the site hospital each month.

CONCLUSION

Transferring patients is workload intensive on nurses' time and should be included in nursing workload measurement systems.

RELEVANCE TO CLINICAL PRACTICE

Nurses at the site hospital spend over 1700 hr each month on activities associated with transferring patients, meaning that less time is available for nursing care.

Organization and Structure of the Cardiothoracic Intensive Care Unit

The purpose of this chapter is to emphasize and describe the team nature of critical care medicine in the Cardiothoracic Intensive Care Unit. The chapter will review the importance of various team members and discuss various staffing models (open vs closed, high intensity vs low intensity, etc.) on patient outcomes and cost. The chapter will also examine the roles of nurse practitioners and physician assistants (NP/PAs) in critical care, and will briefly review the growing role of the tele-ICU. Most studies support the concept that a multi-disciplinary ICU team, led by an intensivist, improves patient outcomes and decreases overall cost of care. The role of the tele-ICU and 24 hour in-house intensivist staffing in improving outcomes is controversial, and more research is needed in this area. Finally, a brief discussion of billing for critical care will be discussed.

Nurse Research Experiences and Attitudes Toward the Conduct of Intensive Care Research: A Questionnaire Study

OBJECTIVE

To characterize ICU nurses' research experience, work environments, and attitudes toward clinical research in critically ill adults and children.

DESIGN

Cross-sectional survey.

SETTING

Eight (seven adult and one pediatric) academic ICUs affiliated with the Canadian Critical Care Trials Group.

PARTICIPANTS

Four hundred eighty-two ICU nurses.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Response rate was 56%. Most participants had over 6 years of ICU experience (61%) and held a baccalaureate nursing degree (57%). Most participants (63%) had provided care for patients receiving research study procedures more than five times in the past 12 months and agreed that research leads to improved care for the critically ill (78%) and eligible patients should be approached for research participation (78%). Few perceived practicalities of nursing care are considered in study design (20%); 41% agreed that research studies increases nursing workload. Few participants reported receiving adequate information about study progress (24%) or findings (26%). Principal factor analysis identified three factors each in the environmental and attitudinal domains. Linear regression models demonstrated that positive relationships between researchers and clinicians were associated with favorable perceptions of research impact on nursing care (p < 0.001), ICU research acceptability (p < 0.001), and nursing engagement in research (p < 0.05). Nurses with more formal education reported more favorable attitudes toward nursing engagement in research (p < 0.01) and research acceptability (p < 0.01). Lack of experience in study protocol development and/or data analysis was associated with less favorable attitudes about nursing engagement in research (p < 0.01) and impact of research on nursing care (p < 0.01).

CONCLUSION

In these research-intensive ICUs, nurses frequently care for research participants and believe ICU research is important. Inclusion of nurses in study protocol development, improved communication of study progress and findings, and investigation of research-related nursing workload are warranted. Such interventions will support intervention fidelity and data reliability during study conduct and translation of evidence into practice on study completion.

Task Analysis as a Resource for Strengthening Health Systems

Task analysis is a descriptive study methodology that has wide application in the health professions. Task analysis is particularly useful in assessment and definition of the knowledge, skills, and behaviors that define the scope of practice of a health profession or occupation. Jhpiego, a US-based nongovernmental organization, has adapted traditional task analysis methods in several countries in assessment of workforce education and practice issues. Four case studies are presented to describe the utility and adaptability of the task analysis approach. Traditional task analysis field survey methods were used in assessment of the general and maternal-child health nursing workforce in Mozambique that led to curriculum redesign, reducing the number of education pathways from 4 to 2. The process of health system strengthening in Liberia, following a long history of civil war conflict, included a traditional task analysis study conducted among 119 registered nurses and 46 certified midwives who had graduated in the last 6 months to 2 years to determine gaps in education and preparation. An innovative approach for data collection that involves "playing cards" to document participant opinions (Task Master, Mining for Data) was developed by Jhpiego for application in other countries. Results of a task analysis involving 54 nurses and 100 nurse-midwives conducted in Lesotho were used to verify the newly drafted scope and standards of practice for nurses and to inform planning for a competency-based preservice curriculum for nursing. The Nursing and Midwifery Council developed a 100-question licensing examination for new graduates following a task analysis in Botswana. The task analysis process in each country resulted in recommendations that were action oriented and were implemented by the country governments. For maximal utility and ongoing impact, a task analysis study should be repeated on a periodic basis and more frequently in countries undergoing rapid change in development of workforce policy.

Comparing the cost-effectiveness and clinical effectiveness of a new community in-reach rehabilitation service with the cost-effectiveness and clinical effectiveness of an established hospital-based rehabilitation service for older people: a pragmatic randomised controlled trial with microcost and qualitative analysis – the Community In-reach Rehabilitation And Care Transition (CIRACT) study

Background

Older people represent a significant proportion of patients admitted to hospital as a medical emergency. Compared with the care of younger patients, their care is more challenging, their stay in hospital is much longer, their risk of hospital-acquired problems is much higher and their 28-day readmission rate is much greater.

Objective

To compare the clinical effectiveness, microcosts and cost-effectiveness of a Community In-reach Rehabilitation And Care Transition (CIRACT) service with the traditional hospital-based rehabilitation (THB-Rehab) service in patients aged ≥ 70 years.

Methods

A pragmatic randomised controlled trial with an integral health economic study and parallel qualitative appraisal was undertaken in a large UK teaching hospital, with community follow-up. Participants were individually randomised to the intervention (CIRACT service) or standard care (THB-Rehab service). The primary outcome was hospital length of stay; secondary outcomes were readmission within 28 and 91 days post discharge and super spell bed-days (total time in NHS care), functional ability, comorbidity and health-related quality of life, all measured at day 91, together with the microcosts and cost-effectiveness of the two services. A qualitative appraisal provided an explanatory understanding of the organisation, delivery and experience of the CIRACT service from the perspective of key stakeholders and patients.

Results

In total, 250 participants were randomised (n = 125 CIRACT service,n = 125 THB-Rehab service). There was no significant difference in length of stay between the CIRACT service and the THB-Rehab service (median 8 vs. 9 days). There were no significant differences between the groups in any of the secondary outcomes. The cost of delivering the CIRACT service and the THB-Rehab service, as determined from the microcost analysis, was £302 and £303 per patient respectively. The overall mean costs (including NHS and personal social service costs) of the CIRACT and THB-Rehab services calculated from the Client Service Receipt Inventory were £3744 and £3603 respectively [mean cost difference £144, 95% confidence interval –£1645 to £1934] and the mean quality-adjusted life-years for the CIRACT service were 0.846 and for the THB-Rehab service were 0.806. The incremental cost-effectiveness ratio (ICER) from a NHS and Personal Social Services perspective was £2022 per quality-adjusted life-year. Although the CIRACT service was highly regarded by those who were most involved with it, the emergent configuration of the service working across organisational and occupational boundaries was not easily incorporated by the current established community services.

Conclusions

The CIRACT service did not reduce hospital length of stay or short-term readmission rates compared with the standard THB-Rehab service, although it was highly regarded by those who were most involved with it. The estimated ICER appears cost-effective although it is subject to much uncertainty, as shown by points spanning all four quadrants of the cost-effectiveness plane. Microcosting work-sampling methodology provides a useful method to estimate the cost of service provision. Limitations in sample size, which may have excluded a smaller reduction in length of stay, and lack of blinding, which may have introduced some cross-contamination between the two groups, must be recognised. Reducing hospital length of stay and hospital readmissions remains a priority for the NHS. Further studies are necessary, which should be powered with larger sample sizes and use cluster randomisation (to reduce bias) but, more importantly, should include a more integrated community health-care model as part of the CIRACT team.

Trial registration

Current Controlled Trials ISRCTN94393315.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Intensive care nurses' practice related to experience and shift worked

OBJECTIVE

To analyse the social representations of nurses about intensive care practices comparing the variables 1) time since graduation and 2) shift worked.

METHOD

Qualitative field research using social representation theory. Individual interviews were conducted and lexical analysis was applied.

STUDY SETTING

Intensive Care Unit of a federal hospital with 21 clinical nurses.

FINDINGS

Day shift nurses are more pragmatic and operationally oriented because they deal directly with the general functioning of the unit. Less experienced nurses face difficulties dealing with intensive care contexts, but have a critical view of their practices, while more experienced nurses apply practical knowledge in their decision-making and actions.

CONCLUSION

The relationship of proximity or distance from patients, mediated by technology, is related to the domains of knowledge that are required to manage technology and to the role technology plays in intensive care.

How Do Residents Spend Their Time in the Intensive Care Unit?

PURPOSE

To describe the work of residents and the distribution of their time in 6 intensive care units (ICUs) of 2 medical centers (MCs).

METHODS

A total of 242 hours of observation to capture data on tasks performed by residents in 6 ICUs, including adult, pediatric, medical and surgical units, were conducted. For each observation period, the percentages of total time spent on each task and on the aggregated task categories were calculated.

RESULTS

Overall, while in the ICUs, residents spent almost half of their time in clinical review and documentation (19%), conversation with team physicians (16%), conversation attendance (6%) and order management (6%). The 2 MCs differed in the time that residents spent on administrative review and documentation (4% in one MC and 15% in the other). The pediatric ICUs were similar in the 2 MCs, whereas the adult ICUs exhibited differences in the time spent on order management and administrative review and documentation.

CONCLUSIONS

While in the ICUs, residents spent most time performing direct patient care and care coordination activities. The distribution of activities varied across 2 MCs and across ICUs, which highlights the need to consider the local context on residents' work in ICUs.

Impact of electronic health record technology on the work and workflow of physicians in the intensive care unit

OBJECTIVE

To assess the impact of EHR technology on the work and workflow of ICU physicians and compare time spent by ICU resident and attending physicians on various tasks before and after EHR implementation.

DESIGN

EHR technology with electronic order management (CPOE, medication administration and pharmacy system) and physician documentation was implemented in October 2007.

MEASUREMENT

We collected a total of 289 h of observation pre- and post-EHR implementation. We directly observed the work of residents in three ICUs (adult medical/surgical ICU, pediatric ICU and neonatal ICU) and attending physicians in one ICU (adult medical/surgical ICU).

RESULTS

EHR implementation had an impact on the time distribution of tasks as well as the temporal patterns of tasks. After EHR implementation, both residents and attending physicians spent more of their time on clinical review and documentation (40% and 55% increases, respectively). EHR implementation also affected the frequency of switching between tasks, which increased for residents (from 117 to 154 tasks per hour) but decreased for attendings (from 138 to 106 tasks per hour), and the temporal flow of tasks, in particular around what tasks occurred before and after clinical review and documentation. No changes in the time spent in conversational tasks or the physical care of the patient were observed.

CONCLUSIONS

The use of EHR technology has a major impact on ICU physician work (e.g., increased time spent on clinical review and documentation) and workflow (e.g., clinical review and documentation becoming the focal point of many other tasks). Further studies should evaluate the impact of changes in physician work on the quality of care provided.

Arterial blood pressure response to head-up tilt test and orthostatic tolerance in nurses

OBJECTIVES

High tolerance to postural changes was examined in nurses.

METHODS

Twelve female nurses and 12 healthy controls underwent a 70° head-up tilt (HUT) test for 10 min. Blood pressure (BP), heart rate (HR), pulse pressure, and hormone levels were measured. Baroreceptor sensitivity (BRS) was calculated using a sequence technique.

RESULTS

HR increased during HUT in both subject groups, with no difference between groups. Systolic BP was rapidly increased by HUT in both subject groups, and was higher in the nurse group than in the control group during the first 2 min of HUT. Pulse pressure decreased during 1-2.5 min of HUT in the control group, but there was no decrease in the nurse group. BRS was decreased by HUT in the nurse group, while it tended to be decreased in the control group. Both during baseline and HUT, BRS was lower in the nurse group than in the control group. Plasma noradrenaline increased with HUT, and the increase was greater in the nurse group than in the control group.

CONCLUSIONS

Although nurse subjects had a lower BRS during HUT than control subjects, they were able to effectively maintain BP during HUT, suggesting that nurse subjects had higher orthostatic tolerance. The better maintenance of BP in nurse subjects appeared to be associated with a compensatory mechanism other than the arterial baroreflex and/or a hemodynamic mechanism.

Strategic threat management: an exploration of nursing strategies in the pediatric intensive care unit

Part of the work of a critical care nurse is to manage the threats that arise that could impede efficient and effective job performance. Nurses manage threats by employing various strategies to keep performance high and workload manageable. We investigated strategic threat management by using the Threat-Strategy Interview. Threats frequently involved technology, staff, or organizational components. The threats were managed by a toolbox of multifaceted strategies, the most frequent of which involved staff-, treatment- (patient + technology), examination- (patient + clinician), and patient-oriented strategies. The profile of strategies for a particular threat often leveraged work facets similar to the work facet that characterized the threat. In such cases, the nurse's strategy was directed at eliminating the threat (not working around it). A description at both a domain invariant level - useful for understanding strategic threat management generally - and a description at an operational, specific level - useful for guiding interventions-- are presented. A structural description of the relationship among threats, strategies, and the cues that trigger them is presented in the form of an evidence accumulation framework of strategic threat management.

A systematic review of teamwork in the intensive care unit: what do we know about teamwork, team tasks, and improvement strategies?

PURPOSE

Teamwork is essential for ensuring the quality and safety of health care delivery in the intensive care unit (ICU). This article addresses what we know about teamwork, team tasks, and team improvement strategies in the ICU to identify the strengths and limitations of the existing knowledge base to guide future research.

METHODS

A keyword search of the PubMed database was conducted in February 2013. Keyword combinations focused on 3 areas: (1) teamwork, (2) the ICU, and (3) training/quality improvement interventions. All studies that investigated teamwork, team tasks, or team interventions within the ICU (ie, intradepartment) were selected for inclusion.

RESULTS

Teamwork has been investigated across an array of research contexts and task types. The terminology used to describe team factors varied considerably across studies. The most common team tasks involved strategy and goal formulation. Team training and structured protocols were the most widely implemented quality improvement strategies.

CONCLUSIONS

Team research is burgeoning in the ICU, yet low-hanging fruit remains that can further advance the science of teams in the ICU if addressed. Constructs must be defined, and theoretical frameworks should be referenced. The functional characteristics of tasks should also be reported to help determine the extent to which study results might generalize to other contexts of work.

Human factors systems approach to healthcare quality and patient safety

Human factors systems approaches are critical for improving healthcare quality and patient safety. The SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety is a human factors systems approach that has been successfully applied in healthcare research and practice. Several research and practical applications of the SEIPS model are described. Important implications of the SEIPS model for healthcare system and process redesign are highlighted. Principles for redesigning healthcare systems using the SEIPS model are described. Balancing the work system and encouraging the active and adaptive role of workers are key principles for improving healthcare quality and patient safety.

Macroergonomics in Healthcare Quality and Patient Safety

The US Institute of Medicine and healthcare experts have called for new approaches to manage healthcare quality problems. In this chapter, we focus on macroergonomics, a branch of human factors and ergonomics that is based on the systems approach and considers the organizational and sociotechnical context of work activities and processes. Selected macroergonomic approaches to healthcare quality and patient safety are described such as the SEIPS model of work system and patient safety and the model of healthcare professional performance. Focused reviews on job stress and burnout, workload, interruptions, patient-centered care, health IT and medical devices, violations, and care coordination provide examples of macroergonomics contributions to healthcare quality and patient safety. Healthcare systems and processes clearly need to be systematically redesigned; examples of macroergonomic approaches, principles and methods for healthcare system redesign are described. Further research linking macroergonomics and care processes/patient outcomes is needed. Other needs for macroergonomics research are highlighted, including understanding the link between worker outcomes (e.g., safety and well-being) and patient outcomes (e.g., patient safety), and macroergonomics of patient-centered care and care coordination.