Workforce management and patient outcomes in the intensive care unit during the COVID-19 pandemic and beyond: a discursive paper

Bottleneck factors impacting nurses' workflow and the opportunity to prioritize improvement efforts: factor analysis

PURPOSE

Minimizing delays in delivering nursing care is paramount for enhancing the overall quality of care. Certain bottleneck variables restrict the workflow of nurses, resulting in extended shift times. This study is designed to pinpoint and analyze the principal factors contributing to bottleneck issues in nursing workflow, to direct improvement endeavors. This study seeks to provide insights into the key variables contributing to nurses' extended shift times, with the ultimate goal of prioritizing efforts for improvement.

METHODS

A descriptive multicenter cross-sectional study was conducted. A scale was developed for this study by the authors after conducting a literature review, subsequently validated, and its reliability was assessed.

RESULTS

Among the 31 bottleneck variables, 29 were retained under three persistent bottleneck factors: (1) Nurse staffing- This pertains to the availability of sufficient nursing staff at all times across the continuum of care; (2) Working environment and quality of care-This refers to the availability of necessary skills and resources for nurses to perform their duties effectively and; (3) Medical devices- This factor concerns the availability of fully functional medical devices required for providing care.

CONCLUSION

Efforts aimed at enhancing the overall healthcare system should concentrate on addressing persistent bottleneck factors. This may involve the implementation of a healthcare workforce management system, the establishment of standards for a conducive and supportive working environment, and the utilization of a standardized system for the management of medical equipment. The outcomes of this study can be utilized by nurses and policymakers to devise comprehensive strategies for improvement.

Intensive care as a specialty of choice for registered nurses: A descriptive phenomenological study

BACKGROUND

Shortage and retention of experienced nurses are crucial matters and internationally acknowledged, particularly in specialty areas such as Critical Care.

AIM

To explore the experiences of registered nurses in their first and fourth years of practice in an adult intensive care unit.

STUDY DESIGN

This descriptive phenomenological study was conducted over 4 years. Eligible participants were interviewed at two different points in their career. Ten registered nurses were interviewed after three to 6 months of employment in an adult intensive care unit (Phase One). Five of the same participants were interviewed in their fourth year of practice (Phase Two).

FINDINGS

Findings related to factors influencing the participants' choice of specialty and their retention are reported in this paper. Two themes emerged from Phase One: a unique environment, positive and negative emotions, unclear expectations, and the journey of a registered nurse. Two themes generated from data collected in Phase Two included a unique environment and being a proficient nurse. In both phases, nurses considered the Intensive Care Unit a stimulating learning environment.

CONCLUSIONS

This paper highlights that the registered nurse's perception of the Intensive Care Unit and Intensive Care Nursing influenced their choice of specialty, and learning opportunities influenced their decision to remain in the Intensive Care Unit.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study inform action areas for healthcare organizations and nursing managers. Challenges, learning opportunities and the nature of critical care nursing should be considered target areas for organizations to promote and develop as part of critical care nurses' retention strategies. Education not only for new graduate nurses but also for all registered nurses should be ongoing.

Perceived barriers and facilitators to preventing hospital-acquired pressure injury in paediatrics: A qualitative analysis

AIM

This qualitative study aimed to identify nurses' and allied health professionals' perceptions and experiences of providing hospital-acquired pressure injury (HAPI) prevention in a paediatric tertiary hospital in Australia, as well as understand the perceived barriers and facilitators to preventing HAPI.

DESIGN

A qualitative, exploratory study of hospital professionals was undertaken using semi-structured interviews between February 2022 and January 2023.

METHODS

Two frameworks, the Capability, Opportunity and Motivation Model of Behaviour (COM-B) and the Theoretical Domains Framework (TDF), were used to give both theoretical and pragmatic guidance. Participants included 19 nursing and allied health professionals and data analysis was informed by the framework approach.

RESULTS

Analysis revealed nine core themes regarding professionals' beliefs about the barriers and facilitators to HAPI prevention practices across seven TDF domains. Themes included HAPI prevention skills and education, family-centred care, automated feedback and prompts, allocation and access to equipment, everybody's responsibility, prioritizing patients and clinical demands, organizational expectations and support, integrating theory and reality in practice and emotional influence.

CONCLUSION

These findings provide valuable insights into the barriers and facilitators that impact paediatric HAPI prevention and can help identify and implement strategies to enhance evidence-based prevention care and prevent HAPI in paediatric settings.

IMPACT

Overcoming barriers through evidence-based interventions is essential to reduce HAPI cases, improve patient outcomes, and cut healthcare costs. The findings have practical implications, informing policy and practice for improved preventive measures, education, and staffing in paediatric care, ultimately benefiting patient well-being and reducing HAPIs.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. The focus of the study is on healthcare professionals and their perspectives and experiences in preventing HAPIs in paediatric patients. Therefore, the involvement of patients or the public was not deemed necessary for achieving the specific research objectives.

Implementation and utilisation of Australian critical care practice standards: What do we know?

BACKGROUND

The Australian College of Critical Care Nurses published the third edition of practice standards (PSs) for specialist critical care nurses in 2015. Higher-education providers currently use these standards to inform critical care curricula; however, how critical care nurses perceive and use PSs in clinical practice is unknown.

OBJECTIVES

The objective of this study was to explore critical care nurses' perceptions about the Australian College of Critical Care Nurses PS for specialty critical care nursing, to understand how the PSs are used in clinical practice, and what opportunities exist to support their implementation.

METHODS

An exploratory qualitative descriptive design was used. A purposive sampling strategy was used, with 12 critical care specialist nurses consenting to participate in semistructured interviews. The interviews were recorded and transcribed verbatim. Transcripts were analysed thematically using an inductive coding approach.

FINDINGS

Three main themes were identified: (i) lack of awareness of the PS; (ii) minimal to no utilisation of the PS in clinical practice and the challenges contributing to this; and (iii) improving the implementation and utilisation of the PS in clinical practice.

CONCLUSIONS

There is a significant lack of awareness and utilisation of the PS in clinical practice. To overcome this, increasing recognition, endorsement, and valuation of the PSs to stakeholders at an individual, health service, and legislative level are suggested. Further research is required to establish relevance of the PS in clinical practice and understand how clinicians use the PS to promote and develop critical care nursing.

Psychological impact of COVID-19 pandemic and turnover intention: The moderating effect of employee work engagement

The study aimed to understand the relationship between the psychological impact of the COVID-19 pandemic and turnover intention and the moderating role of employee engagement. Data were collected via a structured questionnaire through both hand deliveries of printed questionnaires and Google docs from 187 frontline employees in the Ghanaian public sector. The hypotheses were tested using structural equation modeling. There exists a positive and significant relationship between the COVID-19 pandemic and employee turnover intentions. Out of the three dimensions of work engagement, vigor had a significant negative moderating effect on the relationship between psychological impact and turnover intentions. This implies that the positive effect of the psychological impact of COVID-19 on turnover intentions is minimized, where employees have high levels of energy and mental resilience while working, thus their vigor is high rather than low. The study contributes to literature on employee work engagement by using the Job demands-resources model to unravel the specific dimension of employee engagement that can minimize the negative impact of COVID-19 on employees' turnover intention in the public sector in a developing country.

Fatigue as a Cause of Professional Dissatisfaction Among Chinese Nurses in Intensive Care Unit During COVID-19 Pandemic

Aim

To clarify the mediating role of burnout and the moderating role of turnover intention in the association between fatigue and job satisfaction among Chinese nurses in intensive care units (ICU) during the COVID-19 pandemic.

Methods

A cross-sectional survey of fifteen provinces in China was conducted, using an online questionnaire, from December 2020 to January 2021, during the COVID-19 pandemic. A total of 374 ICU nurses (effective response rate: 71.37%) provided sufficient responses. Sociodemographic factors, job demographic factors, fatigue, burnout, job satisfaction, and turnover intention were assessed using questionnaires. General linear modeling (GLM), hierarchical linear regression (HLR) analysis, and generalized additive modeling (GAM) were performed to examine all the considered research hypotheses.

Results

Fatigue was found to be negatively and significantly associated with job satisfaction. Moreover, burnout played a partial mediating role and turnover intention played a moderating role in the relationship between fatigue and job satisfaction.

Conclusion

Over time, a state of physical and mental exhaustion and work weariness among Chinese ICU nurses potentially results in job burnout and consequently promotes the level of job dissatisfaction. The results also found that turnover intention played a moderating role in the relationship between burnout and job satisfaction. Specific policies could be considered to eliminate nurses' fatigue and negative attitudes during times of public health emergencies.

The future of cancer nursing in Europe: Addressing professional issues in education, research, policy and practice

Cancer nursing has evolved to meet the demands of rising cancer incidence, newer and more complex treatment options, and the emergence of specialist roles supporting patients from pre-diagnosis, through treatment, survivorship and end of life care. Nurses are involved in direct and in-direct care of people at risk of, and living with and after cancer in diverse contexts. As a result, nurses are positioned to have a significant influence on the processes and outcomes of cancer care, through education, research, policy, practice and leadership. However, nursing and cancer care face challenges, arising from workforce shortages, under-investment in services and under-representation in decision-making. This paper discusses the evolution of cancer nursing across education, policy, research, profession and practice, and sets an agenda for innovation and disruption across these domains to ensure sustainability of cancer care services and care for people living with and after cancer. We argue for the continued advancement of cancer nursing with critical focus on identifying and addressing inequities in role recognition and access to specialist cancer nursing education throughout Europe. Partnership, exchange of learning, and co-design will be central to progressing education, evidence and policy to support future growth in the cancer nursing workforce and embed cancer nurses in research and policy setting at local, national and international levels.

Staff experiences, perceptions of care, and communication in the intensive care unit during the COVID-19 pandemic in Australia

BACKGROUND

In 2020, during the first wave of the COVID-19 pandemic in Australia, hospital intensive care units (ICUs) revised patient care practices, curtailed visiting, and augmented the use of personal protective equipment to protect patients, staff, and the community from viral transmission.

AIM

The aim was to explore ICU staff experiences and perceptions of care and communication with patients during the COVID-19 pandemic to understand how alternative ways of working have influenced work processes, relationships, and staff morale.

METHODS

This was a qualitative exploratory design study using audio-recorded and transcribed interviews with 20 ICU staff members. Data were analysed using thematic analysis.

FINDINGS

Four major themes were derived from the data: (i) Communication and connection, (ii) Psychological casualties, (iii) Caring for our patients, and (iv) Overcoming challenges. Patient care was affected by diminished numbers of critical care qualified staff, limited staff entry to isolation rooms, and needing to use alternative techniques for some practices. The importance of effective communication from the organisation and between clinicians, families, and staff members was emphasised. personal protective equipment hindered communication between patients and staff and inhibited nonverbal and verbal cues conveying empathy in therapeutic interactions. Communication with families by phone or videoconference was less satisfying than in-person encounters. Some staff members suffered psychological distress, especially those working with COVID-19 patients requiring extracorporeal membrane oxygenation. Moral injury occurred when staff members were required to deny family access to patients. Workload intensified with increased patient admissions, additional infection control requirements, and the need to communicate with families using alternative methods.

CONCLUSION

The results of this study reflect the difficulties in communication during the early stages of the COVID-19 pandemic. Communication between staff members and families may be improved using a more structured approach. Staff reported experiencing psychological stress when separating families and patients or working in isolation rooms for prolonged periods. A flexible, compassionate response to family presence in the ICU is essential to maintain patient- and family-centred care.

What the Joint Commission Medication Management Titration Standards Mean to Quality Care for Complex Patients

ABSTRACT

The Joint Commission (TJC), the nation's largest healthcare accreditor, was founded in the 1950s. Its Standards for Medication Management (MM) of titratable medications focused on prescriptive ordering practices versus reliance on nurse clinical decision making. The use of measurable endpoints to guide nurse decision making regarding medication titration has been the standard of care since the inception of TJC. Evidence to support altering these practice patterns is lacking. Using the 6 aims for the healthcare system (safe, timely, effective, efficient, equitable, and patient-centered) from the National Academy of Medicine, formerly the Institute of Medicine, and the American Association of Critical-Care Nurses Healthy Work Environment essential standards (skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, authentic leadership), this article examines the impact of TJC MM standards on system design in critical care environments.

Expedited upskilling of intermediate care nurses to provide critical care during the COVID-19 pandemic

AIM

Describe the strategy, efficacy and preferred mechanisms of training used to rapidly upskill intermediate care nursing staff to provide critical care during the COVID-19 pandemic.

DESIGN

Descriptive study.

METHODS

The strategy used from March through December 2020 to upskill nurses in an intermediate care unit to administer critical care upon rapid conversion of the intermediate care unit to an intensive care unit for coronavirus disease 2019 is described. Training and education included paired staffing models, interdisciplinary education, skills days and self-directed learning. Nurses engaged in this upskilling process were surveyed to evaluate their confidence in new critical care competencies and educational preferences.

RESULTS

Of 38 intermediate care nurses, 35 completed training and began independent intensive care practice. Nursing confidence in critical care competencies increased steadily. Nurses demonstrated the greatest preference for peer education models, particularly those incorporating the hospital's pre-existing medical intensive care nurses.

PATIENT AND PUBLIC CONTRIBUTIONS

No patient or public contributions were made to this manuscript.

Organizational responses to the COVID-19 pandemic in Victoria, Australia: A qualitative study across four healthcare settings

Objective

Organizational responses that support healthcare workers (HCWs) and mitigate health risks are necessary to offset the impact of the COVID-19 pandemic. We aimed to understand how HCWs and key personnel working in healthcare settings in Melbourne, Australia perceived their employing organizations' responses to the COVID-19 pandemic.

Method

In this qualitative study, conducted May-July 2021 as part of the longitudinal Coronavirus in Victorian Healthcare and Aged Care Workers (COVIC-HA) study, we purposively sampled and interviewed HCWs and key personnel from healthcare organizations across hospital, ambulance, aged care and primary care (general practice) settings. We also examined HCWs' free-text responses to a question about organizational resources and/or supports from the COVIC-HA Study's baseline survey. We thematically analyzed data using an iterative process.

Results

We analyzed data from interviews with 28 HCWs and 21 key personnel and free-text responses from 365 HCWs, yielding three major themes: navigating a changing and uncertain environment, maintaining service delivery during a pandemic, and meeting the safety and psychological needs of staff . HCWs valued organizational efforts to engage openly and honesty with staff, and proactive responses such as strategies to enhance workplace safety (e.g., personal protective equipment spotters). Suggestions for improvement identified in the themes included streamlined information processes, greater involvement of HCWs in decision-making, increased investment in staff wellbeing initiatives and sustainable approaches to strengthen the healthcare workforce.

Conclusions

This study provides in-depth insights into the challenges and successes of organizational responses across four healthcare settings in the uncertain environment of a pandemic. Future efforts to mitigate the impact of acute stressors on HCWs should include a strong focus on bidirectional communication, effective and realistic strategies to strengthen and sustain the healthcare workforce, and greater investment in flexible and meaningful psychological support and wellbeing initiatives for HCWs.

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

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

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

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

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

Effect of an mHealth self-help intervention on readmission after adult cardiac surgery: Protocol for a pilot randomized controlled trial

Aim

To describe a protocol for the pilot phase of a trial designed to test the effect of an mHealth intervention on representation and readmission after adult cardiac surgery.

Design

A multisite, parallel group, pilot randomized controlled trial (ethics approval: HREC2020.331‐RMH69278).

Methods

Adult patients scheduled to undergo elective cardiac surgery (coronary artery bypass grafting, valve surgery, or a combination of bypass grafting and valve surgery or aortic surgery) will be recruited from three metropolitan tertiary teaching hospitals. Patients allocated to the control group with receive usual care that is comprised of in‐patient discharge education and local paper‐based written discharge materials. Patients in the intervention group will be provided access to tailored ‘GoShare’ mHealth bundles preoperatively, in a week of hospital discharge and 30 days after surgery. The mHealth bundles are comprised of patient narrative videos, animations and links to reputable resources. Bundles can be accessed via a smartphone, tablet or computer. Bundles are evidence‐based and designed to improve patient self‐efficacy and self‐management behaviours, and to empower people to have a more active role in their healthcare. Computer‐generated permuted block randomization with an allocation ratio of 1:1 will be generated for each site. At the time of consent, and 30, 60 and 90 days after surgery quality of life and level of patient activation will be measured. In addition, rates of representation and readmission to hospital will be tracked and verified via data linkage 1 year after the date of surgery.

Discussion

Interventions using mHealth technologies have proven effectiveness for a range of cardiovascular conditions with limited testing in cardiac surgical populations.

Impact

This study provides an opportunity to improve patient outcome and experience for adults undergoing cardiac surgery by empowering patients as end‐users with strategies for self‐help.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621000082808.