Missed nursing care before and during the COVID-19 pandemic: A comparative cross-sectional study

Aim

This study aimed to compare perception of nurses about missed care for the patients before and during the coronavirus disease 2019 (COVID-19) in Jordan. It also examined how nurses differed in terms of the type of missed care and the factors that contributed to it before and during the COVID-19 pandemic. Additionally, socio-demographic factors, including gender, educational level, length of clinical experience, work position, age, and type of shift, were examined to evaluate their association with missed nursing care.

Background

Missed nursing care refers to omission of any aspect of required patient care. Missed care lowers patient satisfaction and also leads to adverse hospital outcomes.

Methods

We adopted a cross-sectional design among 260 nurses working in medical/surgical wards and intensive care units. Views of 130 nurses before COVID-19 were compared with views of 130 nurses during the COVID-19 pandemic. We used the Arabic version of the MISSCARE survey. Data were collected between November 2019 and May 2020.

Results

During COVID-19, nurses had significantly higher satisfaction levels and lower levels of absence and intention to leave than nurses before the COVID-19 pandemic. Differences were observed between nurses’ perceptions of missed care before and during the COVID-19 pandemic. It was observed that missed nursing care increased during COVID-19. The inadequate number of staff nurses was the main reason for missed care activities among both groups. Additionally, age and shift type were significantly associated with an increased reason for missed nursing care among both groups.

Conclusion and implications for nursing

Nurses reported higher satisfaction levels and fewer absences and planned departures during this period. Nurse managers should pay attention by maintaining high satisfaction levels and formulating appropriate policies to reduce missed care levels and thus improve patient care quality.     

The impact of a three-tiered model of nursing redeployment during the COVID-19 pandemic: A cross-sectional study

ObjectiveThe COVID-19 pandemic resulted in extreme system pressures, requiring redeployment of nurses to intensive care units. We aimed to assess the impacts of a 3-tiered pandemic surge model on nurses working in intensive care units during the COVID-19 pandemic.MethodologyIn this cross-sectional study, 931 nurses (464 intensive care and 467 redeployed nurses) who worked within four adult units in Western Canada during pandemic surge(s) were invited via email to participate in a survey. The survey explored the impact of redeployment, rapid unit orientations, just-in-time training, and the 3-tiered model of nursing during pandemic surge. Burnout was measured utilizing the Copenhagen Burnout Inventory questionnaire.ResultsA total of 191 survey responses were retained (59 intensive care nurses and 132 redeployed). Survey results are reported by tier, with outcomes varying based on team leadership, intensive care unit, and redeployment nursing roles. Burnout in personal and workplace domains was present amongst all nursing tiers, while only team leadership roles experienced burnout in the patient domain. Overall, team leadership roles and permanent intensive care nurses experienced the highest rates of burnout. Redeployed nurses reported numerous aids to success including support from colleagues, prior experience, and educational supports. Skill-based orientation, ongoing education, optimized scheduling, role clarity, and mitigators of psychological impacts were identified by respondents as potential facilitators of redeployment and surge models.ConclusionNurses working within this tiered model experienced high degrees of burnout, with highest prevalence amongst team leads and intensive care nurses. Optimization of support for and interventions aimed at improving well-being are important considerations going forward.Implications for clinical practiceTargeted strategies are required to support education, role transition, and optimize competency and role clarity during nursing redeployment for overcapacity surge. Essential strategies to support redeployed nurses include individualized competency assessments pre-redeployment and prior to role transitions, pairing redeployed nurses with the same intensive care nurse consistently, and availability of a nurse educator or resource for additional just-in-time training supports. Contingency disaster strategies should also include interventions targeting staff wellness and prevention of burnout, as well as identify scenarios in which redeployment may increase risks of psychological harm. Debriefing and peer-to-peer support models may increase the efficiency of psychological support for nurses, though additional research is required. Lastly, given enaction of tiered models of nursing care is largely a novel occurrence in the intensive care unit, leadership training is required to support frontline nurses taking on supervisory roles within these team models.     

Nursing workforce deployment and intensive care unit strain during the COVID-19 pandemic in Victoria,Australia

BackgroundThe COVID-19 pandemic demanded intensive care units (ICUs) globally to expand to meet increasing patient numbers requiring critical care. Critical care nurses were a finite resource in this challenge to meet growing patient numbers, necessitating redeployment of nursing staff to work in ICUs.ObjectiveOur aim was to describe the extent and manner by which the increased demand for ICU care during the COVID-19 pandemic was met by ICU nursing workforce expansion in the late 2021 and early 2022 in Victoria, Australia.MethodsThis is a retrospective cohort study of Victorian ICUs who contributed nursing data to the Critical Health Information System from 1 December 2021 to 11 April 2022. Bedside nursing workforce data, in categories as defined by Safer Care Victoria’s pandemic response guidelines, were analysed. The primary outcome was ‘insufficient ICU skill mix’—whenever a site had more patients needing 1:1 critical care nursing care than the mean daily number of experienced critical care nursing staff.ResultsOverall, data from 24 of the 47 Victorian ICUs were eligible for analysis. Insufficient ICU skill mix occurred on 10.3% (280/2725) days at 66.7% (16/24) of ICUs, most commonly during the peak phase from December to mid-February. The insufficient ICU skill mix was more likely to occur when there were more additional ICU beds open over the ‘business-as-usual’ number. Counterfactual analysis suggested that had there been no redeployment of staff to the ICU, reduced nursing ratios, with inability to provide 1:1 care, would have occurred on 15.2% (415/2725) days at 91.7% (22/24) ICUs.ConclusionThe redeployment of nurses into the ICU was necessary. However, despite this, at times, some ICUs had insufficient staff to cope with the number and acuity of patients. Further research is needed to examine the impact of ICU nursing models of care on patient outcomes and on nurse outcomes.     

Missed nursing care in emergency departments: A scoping review

BackgroundPatient safety is a global health priority. Errors of omission, such as missed nursing care in hospitals, are frequent and may lead to adverse events. Emergency departments (ED) are especially vulnerable to patient safety errors, and the significance missed nursing care has in this context is not as well known as in other contexts.AimThe aim of this scoping review was to summarize and disseminate research about missed nursing care in the context of EDs.MethodA scoping review following the framework suggested by Arksey and O’Malley was used to (1) identify the research question; (2) identify relevant studies; (3) select studies; (4) chart the data; (5) collate, summarize, and report the results; and (6) consultation.ResultsIn total, 20 themes were derived from the 55 included studies. Missed or delayed assessments or other fundamental care were examples of missed nursing care characteristics. EDs not staffed or dimensioned in relation to the patient load were identified as a cause of missed nursing care in most included studies. Clinical deteriorations and medication errors were described in the included studies in relation to patient safety and quality of care deficiencies. Registered nurses also expressed that missed nursing care was undignified and unsafe.ConclusionThe findings from this scoping review indicate that patients’ fundamental needs are not met in the ED, mainly because of the patient load and how the ED is designed. According to registered nurses, missed nursing care is perceived as undignified and unsafe.     

Mental well-being of intensive care unit nurses after the second surge of the COVID-19 pandemic: A cross-sectional and longitudinal study

ObjectivesTo determine the impact of the second surge of the COVID-19 pandemic (October 2020 to June 2021) on mental well-being of intensive care unit nurses and factors associated with mental health outcomes.MethodsAn online survey was available for Dutch intensive care unit nurses in October 2021, measuring mental health symptoms; anxiety, depression (Hospital Anxiety and Depression Scale), and post-traumatic stress disorder (Impact of Event Scale-6). Additionally, work-related fatigue was measured using the Need For Recovery-11 questionnaire. Previous data from the first surge (March until June 2020) were used to study mental well-being longitudinally in a subgroup of intensive care unit nurses. Logistic regression analyses were performed to determine factors associated with mental health symptoms.ResultsIn total, 589 nurses (mean age 44.8 [SD, 11.9], 430 [73.8 %] females) participated, of whom 164 also completed the questionnaire in 2020. After the second surge, 225/589 (38.2 %) nurses experienced one or more mental health symptoms and 294/589 (49.9 %) experienced work-related fatigue. Compared to the first measurement, the occurrence of mental health symptoms remained high (55/164 [33.5 %] vs 63/164 [38.4 %], p = 0.36) and work-related fatigue was significantly higher (66/164 [40.2 %] vs 83/164 [50.6 %], p = 0.02). Granted holidays as requested (aOR, 0.54; 95 % CI, 0.37–0.79), being more confident about the future (aOR, 0.59; 95 % CI, 0.37–0.93) and a better perceived work-life balance (aOR, 0.42; 95 % CI, 0.27–0.65) were significantly associated with less symptoms.ConclusionThe second surge of the COVID-19 pandemic further drained the mental reserves of intensive care unit nurses, resulting in more work-related fatigue.     

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.     

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

BackgroundCardiovascular nurses’ skills and experiences of cardiac critical care, management of cardiovascular emergencies, and mechanical circulatory support have been considered vital in providing nursing care for COVID-19 patients in intensive care units during the COVID-19 pandemic. To our knowledge, there are no studies have focused on the contribution and experiences of cardiovascular nurses in the critical care of COVID-19 patients.ObjectivesTo explore the experiences of cardiovascular nurses working in a COVID-19 intensive care unit during the pandemic.MethodsThe study was conducted as a qualitative study with phenomenological approach in June-December 2020. Study data were gathered from ten cardiovascular nurses through semi-structured interviews.ResultsSix themes emerged from the interview data: the duties and responsibilities in a COVID-19 intensive care unit; the differences of COVID-19 intensive care unit practices from cardiovascular practices; the transferrable skills of cardiovascular nurses in a COVID-19 intensive care unit; the difficulties encountered working in a COVID-19 intensive care unit; the difficulty of working with personal protective equipment; and the psychosocial effects of working in a COVID-19 intensive care unit.ConclusionCardiovascular nurses made an important contribution to the management of nursing services with their experiences and skills in the COVID-19 pandemic.     

Personality traits affect critical care nursing competence: A multicentre cross-sectional study

ObjectiveTo investigate the relationship between personality traits and critical care nursing competence among critical care nurses.Research methodology/designMulticentre cross-sectional survey using a self-report questionnaire and path modelling, from August 2017 to December 2018.SettingSix intensive care units in Japan.Main outcome measuresWe assessed relationships among the Big Five personality traits and four critical care nursing competencies in nurses.FindingsWe included 211 nurses (77.7% women, 59.2% in their 20 s); 62.6% had 1–5 years’ critical care nursing experience. Among the four competencies, principles of nursing care had a direct positive effect on decision-making (0.77, p < 0.001); decision-making had a direct positive effect on collaboration (0.74, p < 0.001) and nursing interventions (0.77, p < 0.001). The personality traits openness to experience, agreeableness, and extraversion had a significantly positive effect (0.17, p < 0.05; 0.43, p < 0.001; 0.29, p < 0.01; respectively) on principles of nursing care, the key competency. The personality trait neuroticism had a direct or indirect negative effect on all four nursing competencies.ConclusionNursing competence in the critical care setting is affected by personality traits. Our findings can be applied in nursing education to improve competence based on individual personality traits.     

Person-centred care among intensive care unit nurses: A cross-sectional study

ObjectivePractising person-centred care is crucial for nurses in the intensive care unit, as patients have high physical and psychological care needs. We aimed to identify the predictors of person-centred care among nurses working in intensive care settings.MethodsIn this cross-sectional study, 188 intensive care unit nurses at four tertiary hospitals in two cities of South Korea were included. They completed self-reported questionnaires on emotional intelligence, compassion satisfaction, secondary traumatic stress, burnout, and person-centred care. Emotional intelligence was measured using the Korean version of the Wong and Law’s emotional intelligence scale. Compassion satisfaction, secondary traumatic stress, and burnout were measured by the Professional Quality of Life questionnaire (version 5). Person-centred care was measured using the person-centred critical care nursing scale.ResultsMultiple regression identified compassion satisfaction (β = 0.49, p <.001) as the most powerful predictor of person-centred care, followed by emotional intelligence (β = 0.21, p =.004) and intensive care unit career length (β = 0.17, p =.021). These three variables accounted for 31.0 % of the variance in person-centred care.ConclusionsThis study highlights the importance of career length, emotional intelligence, and compassion satisfaction in the promotion of person-centred care among intensive care unit nurses. Nursing management should contemplate specific measures to reduce turnover among experienced intensive care unit nurses and to enhance the factors that promote person-centred care, such as compassion satisfaction and emotional intelligence.     

Development of the nursing practice scale for end-of-life family conferences in critical care

ObjectivesThis study aimed to develop the Nursing Practice Scale for End-of-life Family conferences in critical care and to clarify the current status of nursing practice regarding family conferences.Research methodology/designWe conducted a cross-sectional, self-administered questionnaire survey with 955 critical care unit nurses in 97 hospitals. Content validity, factor validity and criterion-related validity, known-group validity, internal consistency and test–retest reliability were evaluated. Data were then analysed statistically.SettingAdult intensive care units or high dependency units in Japan.ResultsThree factors with 39 items were extracted through item analysis and confirmatory factor analysis as hypothesised (Factor 1: Preparation, Factor 2: Discussion and Factor 3: Follow-up), and the mean score per item for each factor was 3.57, 3.73 and 3.75, respectively. Nurses who had any certification or had worked in critical care unit for >5 years had a significantly greater score than the others. The Cronbach’s α were 0.86–0.96 and the intraclass correlation coefficients were 0.79–0.87.ConclusionThe Nursing Practice Scale for End-of-life Family conferences in critical care is a valid and reliable scale. This study could effectively facilitate communication among patients, their families and healthcare providers.     

Allied health surge capacity in Australian intensive care units during the COVID-19 pandemic: A cross-sectional survey

BackgroundBased on the early international COVID-19 experience, it was anticipated that intensive care services and workforces in Australia would be placed under similar pressure. While surge capacity of medical and nursing workforces was estimated, little was known about baseline allied health staffing, making it difficult to estimate surge capacity and coordinate planning.ObjectivesThe purpose of this study was to (i) capture baseline allied health staffing levels in Australian adult intensive care units (ICUs) prior to the COVID-19 pandemic emergence in Australia and (ii) describe the allied health pandemic planning and surge response in Australian ICUs during the early waves of the pandemic.MethodsThis was a cross-sectional, investigator-devised, prospective survey study. The survey was administered via the national chief allied health network to a convenience sample of senior ICU allied health clinicians at hospitals throughout Australia.ResultsA total of 40 responses were received from tertiary and metropolitan hospitals; 12 (30%) physiotherapists and eight (20%) occupational therapists were the most frequent respondents. Prior to the COVID-19 pandemic, 28 (70%) allied health respondents had a mean (interquartile range) of 1.74 (2.00) full-time equivalent staff designated to the ICU, where these ICUs had a mean of 21.53 (15.00) ventilator beds. Few respondents serviced their ICU on a referral-only basis and did not have dedicated ICU full-time equivalent (12; 20%). Surge planning was mostly determined by discussion within the ICU, allied health department, and/or respective disciplines. This approach meant that allied health staffing and associated decision-making was ad hoc at a local level.ConclusionsThe baseline rate of allied health coverage in Australian ICUs remains unknown, and the variability across allied health and within the specific disciplines is undetermined. Further research infrastructure to capture ICU allied health workforce data is urgently needed to guide future pandemic preparedness.     

Professional identity of Chinese nursing students during the COVID-19 pandemic outbreak: A nation-wide cross-sectional study

Practicing in unprecedented working environment and fighting against the COVID-19 crisis influenced the image of nursing in the general population, as well as among nurses themselves. This study aimed to describe the sense of professional identity among Chinese nursing students during the COVID-19 outbreak and to explore the relationship between psychological resilience and the sense of professional identity in this cohort. A nationwide online cross-sectional survey was conducted. Nursing students were recruited from 18 Chinese universities. The 10-item Connor-Davidson resilience scale (CD-RISC-10) evaluated psychological resilience and professional identity was assessed by the Professional Identity Questionnaire for Nursing Students (PIQNS). A total of 6348 respondents had a moderate level of professional identity to nursing (average PIQNS score at 62.02 ± 12.02). About 86% of respondents attributed the response to the COVID-19 pandemic in elevating the nursing image. Psychological resilience was the strongest contributor to professional identity (β = 0.371, P < 0.001). There was a high level of professional identity among Chinese nursing students during the COVID-19 crisis. Policy support and courses to enhance psychological resilience are critical to sustain professional identity among nursing students.     

Association between psychosocial factors and satisfaction with communication in family members of intensive care unit patients during COVID-19 pandemic: An exploratory cross-sectional study

ObjectiveTo investigate the relationship between satisfaction with communication and perceived stress, depressive symptoms and perceived social support among family members of critically ill.Research Methodology/DesignExploratory, cross-sectional study was conducted.SettingPrivate teaching hospital in Santiago, Chile.Main Outcomes MeasuresFamily members of critically ill patients with 3–7 days of stay and respiratory support were approached. Questionnaires were used to assess satisfaction with communication (Family Satisfaction in the Intensive Care Unit-24), perceived stress (Perceived Stress Scale-10), depressive symptoms (Patient Health Questionnaire-9) and perceived social support (Medical Outcomes Study Social Support Survey). The relationship between satisfaction with communication and relevant variables was investigated using bivariate analyses and a beta regression.ResultsThe study included 42 family members, with 71.4% being female and 52.4% having prior critical care experience. There was a positive correlation between perceived stress and depressive symptoms (r = 0.32, p = 0.039). According to the beta regression, perceived social support (B; 95% confidence interval, 0.44 [1.05–2.29]) and the number of calls with unit staff (0.17 [1.06–1.32]) were positively associated with satisfaction with communication but negatively with college education (−1.86 [0.04–0.64]) and perceived stress (−0.07 [0.87–0.99]).ConclusionPsychosocial factors, such as higher educational level, perceived stress and perceived social support, can influence family members’ evaluation of communication with staff. Current communication practices in acute care settings should be adapted to family members’ psychosocial context to improve their satisfaction with the communication process.Implications for clinical practiceCritical care professionals must be aware of the influence of family member-related factors on the quality and effectiveness of the communication process. Psychosocial features of the family members are likely to impact their satisfaction with communication and should be assessed on admission and during their stay to assist clinicians to adjust and improve their communication practices.     

Quality of life in family caregivers of patients in the intensive care unit: A longitudinal study

BackgroundFamily caregivers of patients in the intensive care unit (ICU) experience impairments in the quality of life. Previous studies report that psychological quality of life improves over time, but there has been limited longitudinal research, and measurement points have differed. Factors such as age, gender, and posttraumatic stress symptoms have been found to be associated with the quality of life, but level of hope and its associations with the quality of life have not been investigated.ObjectivesThe objective of this study was (1) to evaluate changes in the quality of life in family caregivers during the first year after a patient's admission to the ICU and (2) to identify associations between patients' and family caregivers' background characteristics, posttraumatic stress symptoms, hope, and quality of life.MethodsA longitudinal study design with five measurement points was used. Family caregivers completed study questionnaires at enrolment into the study and at 1, 3, 6, and 12 months after the patient's admission to the ICU. The quality of life was measured with the 12-Item Short Form Health Survey.ResultsFamily caregivers (N = 211) reported improved psychological quality of life during the first year after the patient's admission to the ICU, but it was still lower than the psychological quality of life reported in norm-based data. Being on sick leave, consulting healthcare professionals (e.g., general practitioner), and increased level of posttraumatic stress symptoms were significantly associated with psychological quality of life, whereas hope was not. Reported physical quality of life was comparable to norm-based data.ConclusionFamily caregivers of patients in the ICU reported impairments in quality of life during the first year after the patient's admission to the ICU. Being on sick leave, consulting healthcare professionals, and reduced posttraumatic stress symptoms may improve mental quality of life.     

Patient-centered care,nurse work environment and implicit rationing of nursing care in Swiss acute care hospitals: A cross-sectional multi-center study

BackgroundPatient-centered care is a key element of high-quality healthcare and determined by individual, structural and process factors. Patient-centered care is associated with improved patient-reported, clinical and economic outcomes. However, while hospital-level characteristics influence patient-centered care, little evidence is available on the association of patient-centered care with characteristic such as the nurse work environment or implicit rationing of nursing care.ObjectiveThe aim of this study was to describe patient-centered care in Swiss acute care hospitals and to explore the associations with nurse work environment factors and implicit rationing of nursing care.DesignThis is a sub-study of the cross-sectional multi-center “Matching Registered Nurse Services with Changing Care Demands” study.SettingWe included 123 units in 23 acute care hospitals from all three of Switzerland’s language regions.ParticipantsThe sample consisted of 2073 patients, hospitalized for at least 24 h and ≥18 years of age. From the same hospital units, 1810 registered nurses working in direct patient care were also included.MethodsPatients‘ perceptions of patient-centered care were assessed using four items from the Generic Short Patient Experiences Questionnaire. Nurses completed questionnaires assessing perceived staffing and resource adequacy, adjusted staffing, leadership ability and level of implicit rationing of nursing care. We applied a Generalized Linear Mixed Models for analysis including individual-level patient and nurse data aggregated to the unit level.ResultsPatients reported high levels of patient-centered care: 90% easily understood nurses, 91% felt the treatment and care were adapted for their situation, 82% received sufficient information, and 70% felt involved in treatment and care decisions. Higher staffing and resource adequacy was associated with higher levels of patient-centered care, e.g., sufficient information (β 0.638 [95%-CI: 0.30–0.98]). Higher leadership ratings were associated with sufficient information (β 0.403 [95%-CI: 0.03–0.77) and adapted treatment and care (β 0.462 [95%-CI: 0.04–0.88]). Furthermore, higher levels of implicit rationing of nursing care were associated with lower levels of patient-centered care, e.g., adapted treatment and care (β −0.912 [95%-CI: −1.50–0.33]).ConclusionOur study shows a negative association between implicit rationing of nursing care and patient-centered care: i.e.the lower the level of implicit rationing of nursing care, the better patients understood nurses, felt sufficiently informed and recognized that they were receiving highly individualized treatment. To improve patient-centered care, the nurse work environment and the level of implicit rationing of nursing care should be taken into consideration.