Nurses' pandemic lives: A mixed-methods study of experiences during COVID-19

BackgroundThe US healthcare settings and staff have been stretched to capacity by the COVID-19 pandemic. While COVID-19 continues to threaten global healthcare delivery systems and populations, its impact on nursing has been profound.ObjectivesThis study aimed to document nurses' immediate reactions, major stressors, effective measures to reduce stress, coping strategies, and motivators as they provided care during COVID-19.DesignMixed-methods, cross sectional design. Participants responded to objective and open-ended questions on the COVID-19 Nurses' Survey.ParticipantsThe survey, was sent to nurses employed in health care settings during the pandemic; 110 nurses participated.ResultsImmediate reactions of respondents were nervousness and call of duty; major stressors were uncertainty, inflicting the virus on family, lack of personal protective equipment (PPE), and protocol inconsistencies. Effective measures to reduce stress identified were financial incentives and mental health support. Most frequently used coping strategies were limiting televised news about the virus, talking with family and friends, and information, Motivators to participate in future care included having adequate PPE and sense of duty. Bivariate analysis of outcomes by age group, education, work setting, and marital status was performed. Nurse respondents with higher advanced degrees had significantly less fear than those with BSN-only degrees (p < .05).Of respondents who were married/living with a partner, 85.9% listing “uncertainty about when the pandemic will be under control” as a major stressor (p < .05), while 62.8% of those who were single/divorced/widowed (p = .015) did so. Further, 75% of respondents working in critical care listed “mental health services” as important (p = .054). Four major qualitative themes emerged: What is going on here?; How much worse can this get?; What do I do now?; What motivates me to do future work?ConclusionThe study found nurses were motivated by ethical duty to care for patients with COVID-19 despite risk to self and family, leaving nurses vulnerable to moral distress and burnout. This research articulates the need for psychological support, self- care initiatives, adequate protection, information, and process improvements in the healthcare systems to reduce the risk of moral distress, injury and burnout among nurses.     

Talking about persons – Thinking about patients: An ethnographic study in critical care

BackgroundNursing involves caring for the ‘whole person’ and it is considered inappropriate for nurses to think or talk about patients in objectifying or dehumanising ways. Objectifying discourses can dominate within the arena of critical care, and critical care nurses can experience moral distress as they struggle to think about patients as persons. No previous study has examined the role played by ‘impersonal’ talk in the delivery of nursing care. This paper reports a study which examined the relationship between nursing practice and the way(s) in which critical care nurses think and talk about patients.ObjectivesThe study objectives were to (1) identify and characterise the ways in which critical care nurses think and talk about patients; and (2) describe patterns of nursing practice associated with these different ways of thinking.Study designAn ethnographic study was undertaken within one critical care unit in the United Kingdom. Data were collected over 8 months through 92 h of participant observation and 13 interviews. Seven critical care nurses participated in the study. Data analysis adopted the perspective of linguistic ethnography.FindingsAnalysis of these data led to the identification of seven Discourses, each of which was characterised by a particular way of talking about patients, a particular way of thinking about patients, and a particular pattern of practice. Four of these seven Discourses were of particular significance because participants characterised it as ‘impersonal’ to think and talk about patients as ‘routine work’, as a ‘body’, as ‘(un)stable’ or as a ‘medical case’. Although participants frequently offered apologies or excuses for doing so, these ‘impersonal’ ways of thinking and talking were associated with practice that was essential to delivering safe effective care.ConclusionsCritical care practice requires nurses to think and talk about patients in many different ways, yet nurses are socialised to an ideal that they should always think and talk about patients as whole persons. This means that nurses can struggle to articulate and reflect upon aspects of their practice which require them to think and talk about patients in impersonal ways. This may be an important source of distress to critical care nurses and emotional exhaustion and burnout can arise from such dissonance between ideals and the reality of practice. Nursing leaders, scholars and policy makers need to recognise and legitimise the fact that nurses must think about patients in many ways, some of which may be considered impersonal.     

Emergency Medicine/Critical Care Medicine (EM/CCM) Trainees’ Performance on Standardized Critical Care Medicine Examinations: A Ten-Year Review

BackgroundEmergency Medicine/Critical Care Medicine (EM/CCM) trainees may obtain board certification through Internal Medicine (American Board of Internal Medicine [ABIM]), Surgery (American Board of Surgery [ABS]), and Anesthesiology (American Board of Anesthesiology [ABA]). However, EM/CCM trainees experience challenges, including: 1) additional training requirements and 2) an unwillingness to accept EM graduates by many programs.ObjectivesWe sought to: 1) compare EM/CCM knowledge acquisition to medicine (Internal Medicine [IM]/CCM), surgery (surgical critical care [SCC]), and anesthesiology (anesthesiology critical care medicine [ACCM]) Fellows at the local and national level using the Multidisciplinary Critical Care Knowledge Assessment Program (MCCKAP) in-service examination as an objective measure; and 2) compare American Board of Medical Specialties (ABMS) pass rates for EM/CCM.MethodsSingle-center retrospective analysis comparing scores obtained by EM/CCM on the MCCKAP examination with SCC and ACCM over a 10-year period. Scores are presented as means with standard deviations. We performed similar analysis on ABMS examination pass rates.ResultsThere were 117 MCCKAP scores (37 EM/CCM; 80 SCC and ACCM) evaluated. EM/CCM mean score 562.4 (SD 67.4); SCC and ACCM mean score 505.3, (SD 87.5) at the institutional level (p < 0.001). Similarly, EM/CCM scored higher than the national mean (562.4, SD 67.4 vs. 500 SD 100, p < 0.001). Nationally, ABIM-CCM board certification rate was 91.2% for 137 EM/CCM, compared with 93.2% for IM/CCM (p = 0.22); 28 EM/CCM have obtained ABA-CCM board certification with rates similar to ACCM (90.4 vs. 89.3%; p = 0.85).ConclusionsEM/CCM Fellows demonstrate successful knowledge acquisition both locally and at a national level. EM/CCM achieve ABMS pass rates similar to other CCM trainees. The current arbitrary additional training requirements placed on EM/CCM should be removed.     

Influence of spirituality on moral distress and resilience in critical care staff: A scoping review

ObjectiveThe Covid 19 pandemic has created a situation in which critical care staff experience moral distress. For reducing moral distress, resources such as spirituality can be used. The aim of this scoping review is to explore whether spirituality mitigates the moral distress of critical care staff and strengthens their resilience. The spiritual resources will be identified and the ability of the staff to use spiritual resources will be explored.MethodologyA scoping review of studies reporting on the association between spirituality, moral distress, and resilience. Qualitative and quantitative studies from 2020 that examined critical care staff are included. This scoping review used the five-step framework proposed by Arksey and O'Malley and was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework for scoping reviews. The literature searches were conducted in 12 databases.Results13 studies met inclusion criteria. Critical care staff declaring themselves as spiritual have a higher risk of moral distress and are often not able to use spiritual resources on their own. For effective use of spiritual resources to reduce moral distress, staff need to be skilled in the practice of spirituality with the aim to find inner peace, focus on the positive, and regain a sense of purpose in the work.ConclusionSpirituality does not automatically help the critical care staff to cope with moral distress and strengthen resilience. Institutions need to create conditions in which the critical care staff are supported to use their spiritual resources.Implication for clinical practiceInstitutions need to involve staff more in the design, implementation, and delivery of spiritual interventions to minimise moral distress. Further research is necessary to examine the impact of critical care staff’s demographic characteristics on their spirituality, moral distress, and resilience.     

Development and evaluation of a moral distress scale

AIM OF THE STUDY: This methodological research developed and evaluated the moral distress scale from 1994 to 1997. BACKGROUND/RATIONALE: Although nurses confront moral questions in their practice daily, few instruments are available to measure moral concepts. The methodological design used a convenience sample consisted of 214 nurses from several Unites States hospitals. The framework guiding the development of the moral distress scale (MDS) included Jameton's conceptualization of moral distress, House and Rizzo's role conflict theory, and Rokeach's value theory. Items for the MDS were developed from research on the moral problems that nurses confront in hospital practice. The MDS consists of 32 items in a 7-point Likert format; a higher score reflects a higher level of normal distress. RESULTS: Mean scores on each item ranged from 3.9 to 5.5, indicating moderately high levels of moral distress. The item with the highest mean score (M=5.47) was working where the number of staff is so low that care is inadequate. Factor analysis yielded three factors: individual responsibility, not in the patient's best interest, and deception. No demographic or professional variables were related to moral distress. Fifteen percent of the nurses had resigned a position in the past because of moral distress. CONCLUSION: The results support the reliability and validity of the MDS.     

The characteristics and factors associated with omitted nursing care in the intensive care unit: A cross-sectional study

IntroductionPrior research showed that work environment features in acute care settings influence nurses’ capacity to provide care and impacts patient outcomes (e.g., falls). However, little is known about this phenomenon in the intensive care unit. The objectives of this study were to describe the characteristics of omitted nursing care, and to examine the associations between work environment features, omitted nursing care and nurse-reported outcomes in the intensive care unit.MethodsAn electronic cross-sectional correlational study was conducted in the province of Quebec, Canada. Over September 2021, nurses were asked to complete the Healthy Work Environment Assessment Tool (HWEAT), the Intensive Care Unit Omitted Nursing Care instrument (ICU-ONC) and to report their perceptions of nurse-reported outcomes (e.g., quality of care). The associations between these variables were estimated using multivariable cluster-robust regression models, adjusted for nurse and hospital characteristics.ResultsA total of 493 nurses from 42 distinct hospitals participated to this study. On average, nurses felt that their work environment was acceptable, and that the quality and safety of patient care was good. Basic care activities (e.g., mobilisation) were most frequently reported as omitted as opposed to those related to surveillance and medical interventions. In multivariable analyses, higher work environment scores were associated with reduced omitted nursing care scores (p < 0.001) and better ratings for nurse-reported outcomes (p < 0.001). Also, higher omitted nursing care scores were associated with more negative perceptions about the quality and safety of care (p < 0.001).ConclusionOur study portrays the characteristics and some factors associated with omitted nursing care in the intensive care unit. Further research should determine whether intensive care nurses’ reports of organisational features and omitted nursing care are associated with objectively captured patient outcomes.     

Actual and perceived knowledge of type 1 diabetes mellitus among school nurses

BackgroundIn general, school nurses are aware that it is important to have knowledge of type 1 diabetes to give adequate care to children with the disease. Many studies assessing diabetes knowledge have found different deficits among nurses. To our knowledge, however, no study has assessed the knowledge of type 1 diabetes among school nurses.ObjectiveTo assess actual and perceived diabetes knowledge among school nurses.DesignCross-sectional studies.SettingsSeventeen primary care facilities in Warsaw that employed school nurses.ParticipantsTwo hundred and thirty school nurses.MethodsWith the Diabetes Knowledge Questionnaire (DKQ), we assessed actual diabetes knowledge. With the Self-Assessed Diabetes Knowledge (SADK), we assessed perceived diabetes knowledge. Both the DKQ and SADK assessed seven domains of diabetes knowledge: general diabetes knowledge; insulin and glucagon; insulin pumps; diabetes complications; nutrition; physical activity, stress, and comorbidities; and glycemia measurements. We related DKQ and SADK scores to each other and to sociodemographic and work-related factors.ResultsThe rate of correct responses in the DKQ was 46.7%, with the lowest rate regarding knowledge of insulin pumps (36.5%), nutrition (37.4%), and insulin and glucagon (37.9%). Actual and perceived diabetes knowledge were moderately positively correlated (rho = 0.18,p =.009). In six of the seven knowledge domains examined, school nurses perceived their diabetes knowledge better compared with their actual knowledge. DKQ scores were higher in nurses with higher education (p = .024), those who had relatives or friends with diabetes (p = .032), and those who had prior diabetes training (p = .050). Interestingly, DKQ scores were higher among nurses with fewer years of experience (rho = − 0.18, p = .011).ConclusionsThere is a need for additional diabetes training among nursing students and practicing nurses to provide safe and effective care for children with type 1 diabetes.     

The impact of the Fundamental Critical Course on knowledge acquisition in Rwanda

Background Emerging critical care systems have gained little attention in low- and middle-income countries. In sub-Saharan Africa, only 4% of the healthcare workforce is trained in critical care, and mortality rates are unacceptably high in this patient population. Objectives We sought to retrospectively describe the knowledge acquisition and confidence improvement of practitioners who attend the Fundamental Critical Care Support (FCCS) course in Rwanda. Methods We conducted a retrospective study in which we assessed survey data and multiple-choice question data that were collected before and after course delivery. The purpose of these assessments at the time of delivery was to evaluate participants’ perception and acquisition of critical care knowledge.Results Thirty-six interprofessional clinicians completed the training. Performance on the multiple-choice questions improved overall after the course (mean score pre-course of 56.5% to mean score post-course of 65.8%, p-value <0.001) and improved in all content areas with the exception of diagnosis and management of acute coronary syndrome and acute respiratory failure/mechanical ventilation. Both physicians and nurses improved their scores significantly (68.9% to 75.6%, p-value = 0.031 and 52.0% to 63.5%, p-value <0.001, respectively). Self-reported confidence in level of knowledge also increased in all areas. Survey respondents indicated on open-answer questions that they would like the course offerings at least annually, and that further dissemination of the course in Rwanda was warranted. Conclusion Deploying the established FCCS course improved Rwandan healthcare provider knowledge and confidence across most critical care content areas. Therefore, this course represents a good first step in bridging the gaps noted in emerging critical care systems. Contributions of the study Critical care education in sub-Saharan Africa is limited and few staff have formal training. The aim of the study was to determine whether a focused course delivered in Rwanda on critical care management improved knowledge in key areas. Our retrospective study on results from a multiple choice question test and survey indicate that short courses may improve knowledge of critical care management.     

Nurses’ knowledge,experience and self-reported adherence to evidence-based guidelines for prevention of ventilator-associated events: A national online survey

ObjectiveTo explore Australian intensive care nurses’ knowledge of ventilator-associated pneumonia and self-reported adherence to evidence-based guidelines for the prevention of ventilator-associated events.DesignA quantitative cross-sectional online survey was used.SettingThe study was conducted in two Australia intensive care units, in large health services in Victoria and an Australia-wide nurses’ professional association (Australian College of Critical Care Nurses).Main outcome measuresParticipants’ knowledge and self-reported adherence to evidence-based guidelines.ResultsThe median knowledge score was 6/10 (IQR: 5–7). There was a significant positive association between completion of post graduate qualification and their overall knowledge score p = 0.014). However, there was no association (p = 0.674) between participants’ years of experience in intensive care nursing and their overall score. The median self-reported adherence was 8/10 (IQR: 6–8). The most adhered to procedures were performing oral care on mechanically ventilated patients (n = 259, 90.9%) and semi-fowlers positioning of the patient (n = 241, 84.6%). There was no relationship between participants’ knowledge and adherence to evidence-based guidelines (p = 0.144).ConclusionParticipants lack knowledge of evidence-based guidelines for the prevention of ventilator-associated pneumonia. Specific education on ventilator-associated events may improve awareness and guideline adherence.     

Perceived barriers to early goal-directed mobility in the intensive care unit: Results of a quality improvement evaluation

BackgroundA multicentre randomised trial demonstrated improved outcomes for intensive care unit (ICU) patients using early, goal-directed mobility implemented by nurses.ObjectivesThe aim of the study was to evaluate barriers to nursing mobility, using a validated survey, during an ongoing quality improvement (QI) project (2019) in a medical ICU and determine changes from the pre-QI (2017) baseline.MethodsNurses, nurse practitioners, physician assistants, and clinical technicians completed the 26-item Patient Mobilization Attitudes and Beliefs Survey for the ICU (PMABS-ICU). An overall score and three subscale scores (knowledge, attitudes, behaviour), each ranging from 0 to 100, were calculated; higher scores indicated greater barriers.ResultsSeventy-five (93% response rate) nurses, eight (100%) nurse practitioners and physician assistants, and 11 (100%) clinical technicians completed the PMABS-ICU. For all respondents (N = 94), the mean (standard deviation) overall PMABS-ICU score was 32 (8) and the knowledge, attitudes and behaviour subscale scores were 22 (11), 33 (11), and 34 (8), respectively. Among all respondents completing the survey in both 2017 and 2019 (N = 46), there was improvement in the mean (95% confidence interval) overall score [?3.1 (?5.8, ?0.5); p = .022] and in the knowledge [?5.1 (?8.9, ?1.3); p = .010] and attitudes [?3.9 (?7.3, ?0.6); p = .023] subscale scores. Among all respondents (N = 48) taking the PMABS-ICU for the first time in 2019 compared with those taking the survey before the QI project in 2017 (N = 99), there was improvement in the mean (95% confidence interval) overall score [?3.8 (?6.5, ?1.1); p = .007] and in the knowledge [?6.9 (?11.0, –2.7); p = .001] and attitude [?4.3 (?8.1, –0.5); p = .027] subscale scores.ConclusionsUsing a validated survey administered to ICU nurses and other staff, before and during a structured QI project, there was a decrease in perceived barriers to mobility. Reduced barriers among those taking the survey for the first time during the QI project compared with those taking the survey before the QI project suggests a positive culture change supporting early, goal-directed mobility implemented by nurses.     

Safety culture in two metropolitan Australian tertiary hospital intensive care units: A cross-sectional survey

BackgroundSafety culture is significant in the complex intensive care environment, where the consequences of human error can be catastrophic. Research within Australian intensive care units has been limited and little is understood about the safety culture of intensive care units in Queensland.AimThe aim was to evaluate and compare safety culture in the intensive care units of two metropolitan tertiary hospitals in Queensland.MethodA cross-sectional survey, Safety Attitudes Questionnaire, was administered to all medical, nursing and allied health professionals in the research sites (A and B) during January and February 2016. Data were collated into six safety culture domains of teamwork climate, safety climate, job satisfaction, stress recognition, working conditions and perceptions of management. Comparison was made using t-tests and between demographic groups using generalising estimating equations.ResultsIn total, 206 surveys were returned from 522 staff (39.5% response rate). The majority of respondents were nurses (80.6%). Site B scored all domains of the safety attitudes questionnaire significantly higher than Site A (p < 0.001). The scores for both site A and B were significantly higher in all domains (p < 0.001) than a previous Australian study conducted in 2013. Both sites returned low scores in the stress recognition domain. Medical staff perceived the teamwork climate as more positive than nursing staff (mean difference 16.6 [Wald χ² = 10383.8, p < 0.001]). Allied health professionals reported poorer perceptions of working conditions than medical staff (mean difference 7.8 [Wald χ² = 775.4, p < 0.001]).ConclusionDespite similar governance and external structures, differences were found in safety culture between the two research sites. This finding emphasises the importance of local, unit-level assessment of safety culture and planning of improvement strategies. This study adds to the evidence and implications for critical care clinical practice that these interventions need to be unit focused, supported by management and multidisciplinary in approach.     

Assessing Preoperative Anxiety: Nurses Versus Health Care Assistants

PurposeOur objective was to compare the difference in anxiety levels self-reported by patients and those estimated by health care assistants and nurses in two ambulatory surgery settings.DesignWe performed a prospective study.MethodsPatients’ preoperative anxiety was graded using a visual analog scale.FindingsBetween September 1 and November 31, 2019, a total of fifteen health care assistants and fourteen nurses assessed anxiety scores of 170 patients, including 92 women and 78 men. At admission, the mean visual analog scale anxiety score declared to health care assistants and nurses was 5.3 (SD = 2.9) and 4.2 (SD = 3.1), respectively (P = .02). The correlation between health care assistants’ assessment of the patients' anxiety and the declared level of anxiety was significantly higher than nurses' assessment (r = 0.83 vs r = 0.12; P < .001).ConclusionsNurse assistants estimate patients’ preoperative anxiety with more accuracy than nurses in our hospital. Nursing education curriculum should continue to include addressing preoperative patient anxiety.     

The impact of the COVID-19 pandemic on critical care healthcare professionals' work practices and wellbeing: A qualitative study

BackgroundBurnout and other psychological comorbidities were evident prior to the COVID-19 pandemic for critical care healthcare professionals (HCPs) who have been at the forefront of the health response. Current research suggests an escalation or worsening of these impacts as a result of the COVID-19 pandemic.ObjectivesThe objective of this study was to undertake an in-depth exploration of the impact of the evolving COVID-19 pandemic on the wellbeing of HCPs working in critical care.MethodsThis was a qualitative study using online focus groups (n = 5) with critical care HCPs (n = 31, 7 medical doctors and 24 nurses) in 2021: one with United Kingdom–based participants (n = 11) and four with Australia-based participants (n = 20). Thematic analysis of qualitative data from focus groups was performed using Gibbs framework.FindingsFive themes were synthesised: transformation of anxiety and fear throughout the pandemic, the burden of responsibility, moral distress, COVID-19 intruding into all aspects of life, and strategies and factors that sustained wellbeing during the pandemic. Moral distress was a dominant feature, and intrusiveness of the pandemic into all aspects of life was a novel finding.ConclusionsThe COVID-19 pandemic has adversely impacted critical care HCPs and their work experience and wellbeing. The intrusiveness of the pandemic into all aspects of life was a novel finding. Moral distress was a predominate feature of their experience. Leaders of healthcare organisations should ensure that interventions to improve and maintain the wellbeing of HCPs are implemented.