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.     

Nurse decision-making when managing noradrenaline in the intensive care unit: A naturalistic observational study

ObjectiveIntensive care nurses care for critically ill patients in a complex, fast paced environment. Management of noradrenaline (norepinephrine) is core business for intensive care nurses and nurse decision-making on noradrenaline is poorly understood. The study objective was to investigate decision-making processes nurses use when caring for intensive care unit patients receiving noradrenaline.Research MethodologyA qualitative exploratory design used the Cognitive Continuum Theory as a framework for naturalistic observations and interviews in two medical/surgical intensive care units in Melbourne, Australia.Main Outcome MeasuresObservational and interview data from field notes and audiovisual recordings were transcribed and coded to develop themes using reflexive thematic analysis.FindingsFourteen nurse and patient dyads were recruited to observational sessions from December 2019 to June 2021. Three major themes developed were Learning through doing; Individualised patient care; and Clinical expertise, with six supporting sub-themes. Nurses learned to manage noradrenaline experientially and developed titration and weaning strategies to support decision-making. Blood pressure targets and monitor alarms were used consistently to aid decision-making processes. Nurses were observed practicing across the cognitive continuum depending on knowledge structure, complexity of interventions, response time, and patient acuity.ConclusionExperiential learning of complex and high-risk interventions in the absence of guidelines or algorithms meant nurses developed their own titration and weaning strategies based on constant evaluation and re-evaluation of patient cues. Patient heterogeneity, cue ambiguity and a dynamic practice environment contributed to decision-making complexity that would benefit from development of evidence-based practice resources.Implications for Clinical PracticeNurses learn to manage noradrenaline through experiential learning, using blood pressure targets and monitor alarms to support decision-making when titrating and weaning noradrenaline. Nurses develop noradrenaline titration and weaning strategies to support decision-making in the absence of guidelines or algorithms. Supporting nurse decision-making and streamlining practice would reduce practice variation and cognitive workload.     

Implementation and sustainment strategies for open visitation in the intensive care unit: A multicentre qualitative study

ObjectiveOpen visitation in adult intensive care units has been associated with improved family and patient outcomes. However, worldwide adoption of this practice has been slow and reasons for this are unclear. This study documents barriers and strategies for implementing and sustaining open visitation in adult intensive care units in the United States experienced by nursing leadership.Research designQualitative approach using grounded theory.ParticipantsNurse leaders in adult intensive care units with open visitation.SettingMagnet® or Pathway to Excellence® designated hospitals in the United States.MethodsSemi structured interviews were conducted with 19 nurse leaders from 15 geographically dispersed hospitals. Interviews were recorded, transcribed and imported into Atlas.ti qualitative software for analysis. Grounded theory constant comparison analysis was used for coding and category development.FindingsThe analysis revealed three barriers; nursing attitudes and clinical and nonclinical barriers. Strategies to overcome these barriers were empathy, evidence-based practice, models of care, shared governance, nurse discretion, security and family spaces.ConclusionIntensive care nursing leadership experienced distinct barriers and strategies during pre-implementation, implementation and sustainment of open visitation. Other nursing leaders interested in open visitation can use these findings as they plan this transition in their intensive care units.     

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.     

Critical care nurses’ lived experiences of interhospital intensive care unit-to-unit transfers: A phenomenological hermeneutical study

ObjectiveTo explore critical care nurses’ lived experiences of transferring intensive care patients between hospitals.MethodsA phenomenological hermeneutic approach using data generated through individual interviews with 11 critical care registered nurses.SettingTwo general intensive care units in Sweden.FindingsFive themes were identified: it depends on me; your care makes a difference; being exposed; depending on interprofessional relationships; and sensing professional growth. These themes were synthesised into a comprehensive understanding showing how transferring intensive care patients between hospitals meant being on an ambivalent journey together with the patient but also on a journey within yourself in your own development and growth, where you, as a nurse, constantly are torn between contradictory feelings and experiences.ConclusionInterhospital intensive care unit-to-unit transfers can be a challenging task for critical care nurses but also an important opportunity for professional growth. During the transfer, nurses become responsible for the patient, their colleagues and the entire transfer process. In a time of an increasing number of interhospital intensive care unit-to-unit transfers, this study illuminates the risk for missed nursing care, showing that the critical care nurse has an important role in protecting the patient from harm and safeguarding dignified care.     

Nurses’ perceptions on the skills,knowledge, and attributes required to provide healthcare to people experiencing homelessness in Australia: A qualitative study

BackgroundPeople experiencing homelessness have unmet healthcare needs often related to chronic health conditions and injury. Nurses are often the first and only point of contact for people experiencing homelessness accessing healthcare. However, education that prepares them to meet the needs of this vulnerable population is limited.AimTo qualitatively explore nurses’ perceptions on the skills, knowledge, and attributes required to provide healthcare to people experiencing homelessness in Australia that could underpin an educational pathway.DesignSemi-structured interviews with registered nurses and nurse practitioners.MethodsParticipants of a national survey were invited to undertake an interview. Interview data were analysed thematically and reported here in accordance with the Consolidated Criteria for Reporting Qualitative Research guidelines.FindingsThe registered nurses (n = 11) and nurse practitioners (n = 6) had varying levels of experience providing care for homeless Australians. Overarching themes that arose from the registered nurse and nurse practitioner participants included equitable access to care, knowledge around homelessness, contribution of nursing, and nurses’ role. However, nurse practitioners had a greater sense of agency and empowerment to enact care, while registered nurses perceived being underprepared and overwhelmed by the unmet needs of people experiencing homelessness.ConclusionsThe findings suggest that nursing practice holds opportunities to improve access and care provision for people experiencing homelessness. Capitalising on these opportunities requires that nurses are educationally prepared with the skills, knowledge, and attributes to meet the needs of this vulnerable population without necessarily becoming nurse practitioners. These findings will be used to underpin the development of an educational pathway for nurses to enhance their response to homeless populations.     

Ventilation bundle compliance in two Australian intensive care units: An observational study

BackgroundThe ventilation bundle has been used in adult intensive care units to decrease harm and improve quality of care for mechanically ventilated patients. The ventilation bundle focuses on prevention of specific complications of mechanical ventilation; ventilator-associated pneumonia, sepsis, barotrauma, pulmonary oedema, pulmonary embolism, and acute respiratory distress syndrome. The Institute for Healthcare Improvement ventilation bundle consists of five structured evidence-based interventions: head of the bed elevation at 30–45°; daily sedation interruptions and assessment of readiness to extubate; peptic ulcer prophylaxis; deep vein thrombosis prophylaxis; and daily oral care with chlorhexidine.ObjectivesThe objective of the study was to evaluate the use of the ventilation bundle in two intensive care units in Victoria, Australia.MethodsThis is a 3-month prospective observational study in two intensive care units. Patient medical records were reviewed on days 3, 4, and 5 of mechanical ventilation using a prevalidated ventilation bundle checklist.ResultsA total of 96 critically ill patients required mechanical ventilation for more than 2 d. Patients had a mean age of 64.50 y (standard deviation = 14.89), with an Acute Physiology, Age, Chronic Health Evaluation (APACHE) III mean score of 79.27 (standard deviation = 27.11). The mean ventilation bundle compliance rate was 88.3% on the three consecutive mechanical ventilation days (day 3 = 79.4%, day 4 = 91.1%, and day 5 = 96.7%). There was a statistically significant difference in the mean APACHE III score between patients who had head of bed elevation and those without head of bed elevation, on days 3 (p = <0.001) and 4 (p = 0.007).ConclusionThe ventilation bundle elements were used in Australian intensive care units. The likelihood of having all ventilation bundle elements on day 3 was low if the patient's APACHE III score was high. However, the ventilation bundle compliance rate increased with mechanical ventilation days.     

Central venous catheter access and procedure compliance: A qualitative interview study exploring intensive care nurses’ experiences

ObjectiveTo explore intensive care nurses’ experiences with and perceptions of using a standardised central venous catheter procedure to prevent bacterial contamination when accessing patients’ central venous catheters.Design and methodologyThis study employed an interpretative qualitative design. Data was collected through semi-structured, individual interviews and Qualitative Content Analysis was used in data analysis.SettingSeven Norwegian intensive care nurses were recruited using a purposeful sampling strategy.FindingsThree main themes were identified. 1). Individualised practice revealed varying knowledge of and commitment to following the central line procedure. 2). Risk desensitisation revealed a continuous use of central lines, acute situations and a lack of information on infections, which affect usage. 3). Professional working culture showed nurse-to-nurse interaction, which promoted compliance with the procedure. Their interplay created a team spirit whereby nurses worked together to improve patient safety.ConclusionsThis study shows the diversity and complexity of factors affecting intensive care nurses’ procedure compliance when accessing central lines. The themes of Individualised practice and Risk desensitisation pose a substantial threat to healthcare quality and patient safety in the ICU. Exposure to infection risks could be reduced by applying these themes to inform and strengthen continuing education programs and audit processes. The theme of Professional working culture shows the positive influence nurses can have on each other, promoting compliance when accessing central lines. Intensive care nurses should be aware that their voice matters and that challenging poor practice does not have to be confrontational. Leadership should look for ways to encourage this type of nurse-to-nurse interaction.     

Nurse and Physician Perceptions of Working With Goal-Directed Therapy in the Perioperative Period

PurposeTo explore nurse and physician perceptions of working with and collaborating about arterial wave analysis for goal-directed therapy to identify barriers and facilitators for use in anesthesia departments, postanesthesia care units, and intensive care units.DesignA qualitative study drawing on ethnographic principles in a field study using the technique of nonparticipating observation and semistructured interviews.MethodsData collection occurred using semistructured interviews with nurses (n = 23) and physicians (n = 12) and field observations in three anesthetic departments. An inductive approach for content analysis was used.FindingsThe results showed one overarching theme Interprofessional collaboration encourage and impede based on three categories: (1) interprofessional and professional challenges; (2) obtaining competencies; and (3) understanding optimal fluid treatment.ConclusionsSeveral barriers identified related to interprofessional collaboration. Nurses and physicians were dependent on each other's skills and capabilities to use arterial wave analysis. Education of nurses and physicians is important to secure optimal use of goal-directed therapy.     

Being an intensive care nurse related to questions of withholding or withdrawing curative treatment

Aims and objectives. The aim of the study was to acquire a deeper understanding of what it is to be an intensive care nurse in situations related to questions of withholding or withdrawing curative treatment. Background. Nurses in intensive care units regularly face critically ill patients. Some patients do not benefit from the treatment and die after days or months of apparent pain and suffering. A general trend is that withdrawal of treatment in intensive care units is increasing. Physicians are responsible for decisions concerning medical treatment, but as nurses must carry out physicians’ decisions, they are involved in the consequences. Design and methods. The research design was qualitative, based on interpretative phenomenology. The study was carried out at an adult intensive care unit in Norway. Data were collected by group interviews inspired by focus group methodology. Fourteen female intensive care nurses participated, divided into two groups. Colaizzi's model was used in the process of analysis. Results. The analysis revealed four main themes which captured the nurses’ experiences: loneliness in responsibility, alternation between optimism and pessimism, uncertainty – a constant shadow and professional pride despite little formal influence. The essence of being an intensive care nurse in the care of patients when questions were raised concerning curative treatment or not, was understood as ‘being a critical interpreter and a dedicated helper.’ Conclusions. The findings underpin the important role of intensive care nurses in providing care and treatment to patients related to questions of withholding or withdrawing curative treatment. Relevance to clinical practice. The findings also show the need for physicians, managers and intensive care nurses themselves to recognize the burdens intensive care nurses carry and to appreciate their knowledge as an important contribution in decision making.     

Impact of an education program on the performance of nurses in providing oral care for mechanically ventilated children

BackgroundMechanically ventilated children are prone to pneumonia due to immobilization and lack of laryngeal (cough) reflex and swallowing. Nurses are directly responsible for many clinical approaches used to prevent ventilator-associated pneumonia.ObjectiveThe research objective is to determine the effectiveness of the nurse education program on the performance of nurses in providing oral care for mechanically ventilated children.MethodsThis quasi-experimental pretest-posttest design was conducted on 100 nurses (50 in each of the control and intervention groups) in pediatric intensive care units (PICU) in Tehran, 2015. The research tools included a demographic form and three checklists for evaluation of performance according to the clinical practice guidelines for the oral health status of children in PICU. Before intervention, the performance of nurses in both groups was observed at three stages and three different shifts, using an observational checklist. After one month, their performance was observed again with the same checklist at three stages and three different shifts in the PICU. The training was done in four 40-50 minute sessions in a workshop with a 4-week follow-up. The Chi-square test, Fisher’s exact test, paired t-test, independent t-test, and regression analysis comprised the tools used to analyze the data.FindingsThe mean performance scores of nurses before the education program in the intervention and control groups were 42.8 (±18.5) and 48.7 (±15.7), respectively. These scores improved to 68.6 (±31.4) and 48.6 (±15.4) four weeks after the intervention (p < 0.001).ConclusionThe performance of nurses in providing oral care for mechanically ventilated children improved after the intervention. It is recommended to implement this program for all nurses, regardless of their ward or specialty, based on the clinical practice guidelines. The periodic refreshing in-service training program should be provided to nurses in PICU in order to enhance their performance in providing oral care.