Nursing interventions in palliative care in the intensive care unit: A systematic review

ContextPatients in palliative care are found in different places where care is provided, including the intensive care environment with important role of the nursing staff.ObjectiveThe aim of this systematic review was to answer the following question: which nursing interventions are aimed to the palliative care patients who are in the intensive care unit (ICU).Data sourcesUS National Library of Medicine (PUBMED), Virtual Health Library (BVS), SciELO, The Cochrane Library (Cochrane) and Lilacs databases were used.Data extractionAfter applying inclusion and exclusion criteria in accordance with the PRISMA method, a total of 36 entries published between 2010 and 2020 were used.Data analysisThe records extracted were analyzed from a qualitative approach, so no statistical analysis was carried out.ResultsThe findings demonstrated that the interventions that focus on promoting the patient's autonomy and respect their needs on ICU involves effective communication, promoting shared decision with patient and family, individualize care for each patient including the family on the daily care and decisions, maintaining basic nursing care as hygiene and comfort and encouraging self-care, as well as the involvement of nursing palliative care specialists the care is important. Other interventions included promoting a continuing education program for the nursing staff and other professionals involved in caring for patients in palliative care at ICU.ConclusionThis review highlighted the need for specific nursing interventions aimed at palliative care patients at ICU to promote patient autonomy and the focus on patient needs, always sharing decisions with the patient and family. However, it showed that there is a need for the continuous training of the nursing staff because factors such as the nurses’ lack of technical-scientific knowledge and, concomitantly, the absence of a standardized and specific intervention model linked to a bureaucratic system, make it difficult to carry out a specialized care for this type of patient.     

Survey on the actual number of nurses required for critical patients with COVID-19 in Japanese intensive care units: Preliminary report

Determining the number of nurses required for patients with coronavirus disease receiving mechanical ventilation and/or veno-veno extracorporeal membrane oxygenation is important to provide quality care. Therefore, we conducted this cross-sectional survey of 725 intensive care units in Japan. Data from 152 units with experience of managing patients with coronavirus disease who required tracheal intubation were analyzed. The median number of nurses required for a patient receiving mechanical ventilation or veno-veno extracorporeal membrane oxygenation was two. This number was more than that according to the Japanese standard determined by government. We conclude that more nursing staff is required for caring for patients critically ill with coronavirus disease in intensive care units.     

A survey of ward nurses attitudes to the Intensive Care Nurse Consultant service in a teaching hospital

The aim of an Intensive Care Nurse Consultant (ICNC) service is to optimise care of complex ward patients and reduce adverse events. Despite their widespread implementation, specific assessment of ward nurses' attitudes towards such is lacking. Accordingly, we surveyed ward nurses' attitudes towards our ICNC service in five domains: (a) accessibility and approachability; (b) perceived ICNC skill and knowledge; (c) perceived influence on patient management; (d) usefulness as a resource of clinical information; (e) impact upon adverse outcomes. To achieve this, an anonymous Liker-type questionnaire was distributed to 208 ward nurses in our hospital. We also included space for free text. Completed questionnaires were entered manually into a SURVEYMONKEY? pro-forma to permit automatic report generation and results summary. The major findings were that ICNC staff were perceived as being approachable and good communicators, were skilled at early detection of deteriorating patients, and that they reduce serious adverse events. In addition, nurses believe the ICNC service provides continuity of care post discharge from the intensive care unit (ICU), as well as assisting staff to prioritise clinical issues following medical emergency team (MET) review or ICU discharge. The ward nurses did not believe that the ICNC service reduced their skills in managing ward patients. In contrast, respondents stated that the ICNC service needed to improve the processes of referral to allied health and education of ward staff regarding deteriorating patients. Finally, ward nurses suggest they would call the MET service rather than the ICNC service for patients who had already deteriorated. This survey suggests that the ICNC service is valued, and is perceived to prevent the development of adverse events, rather than playing a major role in the management of the deteriorating patient. There is a need to improve referrals to allied health and further educate ward nurses.     

Factors that contributed to burnout among intensive care nurses during the COVID-19 pandemic in Saudi Arabia: A constructivist grounded theory

BackgroundIntensive care unit (ICU) nurses experience high levels of burnout during the COVID-19 pandemic due to multiple stressors. It has long been known that burnout is negatively associated with patient and staff outcomes. Understanding the triggers for intensive care nurses’ burnout during the pandemic can help to develop appropriate mitigation measures.ObjectiveThe objective of this study was to examine intensive care nurses’ experiences during the COVID-19 pandemic in Saudi Arabia to develop insights into the factors that influenced burnout.MethodsThe study was informed by a constructivist grounded theory design. The study was conducted in an adult ICU in a tertiary hospital in the Makkah province in the Kingdom of Saudi Arabia. All participants were registered nurses with at least 6 months’ experience in intensive care and experienced caring for COVID-19 patients.FindingsThis paper reports on preliminary findings from interviews with 22 intensive care nurses. A core category ‘pandemic pervasiveness’ was identified from the interview data, which makes reference to the ever-present nature of the pandemic beyond the ICU context. Family, work, and the wider world context are the three groups of contextual factors that influenced nurses' experience and perception of burnout.ConclusionMany issues identified from the findings in this study can be attributed to shortages in the intensive care nursing workforce. Thus, we join others in calling for healthcare organisations and policymakers to be creative in finding new ways to meet nurses' needs, motivate, and empower them to maintain and sustain the nursing workforce in highly demanding areas, such as ICUs. Nursing managers can play a crucial role in mitigating nurses’ burnout by identifying and tackling sources of stress that exist among their staff, specifically team conflict, workplace harassment, and discrimination.     

重症监护室护士工作压力调查

目的了解重症监护室（ICU）护士工作中主要的压力源及主要的工作压力，为护理管理者有效地帮助ICU护士减轻工作压力提供依据。方法采用问卷调查法对87名ICU护士、83名病房护士的工作压力进行调查分析。结果在护理专业及工作方面的问题、工作量及时间分配问题和患者护理方面的问题有明显差异；主要工作压力均比病房护士高；工作压力随工龄增加明显升高。结论建议管理者减少或消除护士压力源，并对护士进行业务培训和心理压力承受训练，减轻ICU护士各方面负担，提高工作效率。     

Providing continuity of care for patients transferred from ICU

Patients requiring treatments previously only undertaken in critical care units are now being nursed in other ward areas. A study was carried out to determine the difficulties that are faced by ward nurses caring for this highly dependent patient group. Staff and patient stress were problems experienced and there was a call for closer liaison between ICU and ward staff.     

Effectiveness of a simulation-based educational program in a pediatric cardiac intensive care unit

Optimal staff performance of resuscitation skills is best achieved through regular effective training. However, providing this teaching in a busy high-acuity pediatric cardiac intensive care unit (ICU) had become a challenge due to time and logistical constraints. A program to effectively and efficiently teach ICU nurses the skills necessary in patient resuscitation was developed using simulation training to better meet staff learning needs. Training via simulation provides an ideal learning environment with hands-on experience with the roles required in patient resuscitation. A simulation training program incorporating simulation training was developed for ICU nursing staff. All staff nurses in the ICU were required to attend over a year's time. The program involved mock resuscitation scenarios in which participants performed various resuscitation roles, followed by video review and group debriefing. All participants completed a survey prior to and immediately following participation in the training and again at 1 year. Data collected included self-report of knowledge, skill, and comfort related to patient resuscitation. Data revealed statistically significant improvement in scores pre and post training and at 1 year for self-reported knowledge, skills, and comfort related to resuscitation. Nursing staff reported that simulation training in resuscitation skills was helpful and positively impacted their knowledge, comfort, and skills. Feedback from nursing staff continues to be very positive, and performance of actual resuscitations on the unit has improved anecdotally.     

Nursing handover from ICU to cardiac ward: Standardised tools to reduce safety risks

BackgroundStandardising handover processes and content, and using context-specific checklists are proposed as solutions to mitigate risks for preventable errors and patient harm associated with clinical handovers.ObjectivesAdapt existing tools to standardise nursing handover from the intensive care unit (ICU) to the cardiac ward and assess patient safety risks before and after pilot implementation.MethodsA three-stage, pre-post interrupted time-series design was used. Data were collected using naturalistic observations and audio-recording of 40 handovers and focus groups with 11 nurses. In Stage 1, examination of existing practice using observation of 20 handovers and a focus group interview provided baseline data. In Stage 2, existing tools for high-risk handovers were adapted to create tools specific to ICU-to-ward handovers. The adapted tools were introduced to staff using principles from evidence-based frameworks for practice change. In Stage 3, observation of 20 handovers and a focus group with five nurses were used to verify the design of tools to standardise handover by ICU nurses transferring care of cardiac surgical patients to ward nurses.ResultsStage 1 data revealed variable and unsafe ICU-to-ward handover practices: incomplete ward preparation; failure to check patient identity; handover located away from patients; and information gaps. Analyses informed adaptation of process, content and checklist tools to standardise handover in Stage 2. Compared with baseline data, Stage 3 observations revealed nurses used the tools consistently, ward readiness to receive patients (10% vs 95%), checking patient identity (0% vs 100%), delivery of handover at the bedside (25% vs 100%) and communication of complete information (40% vs 100%) improved.ConclusionClinician adoption of tools to standardise ICU-to-ward handover of cardiac surgical patients reduced handover variability and patient safety risks. The study outcomes provide context-specific tools to guide handover processes and delivery of verbal content, a safety checklist, and a risk recognition matrix.     

Meeting the challenge: ICU-nurses’ experiences of lightly sedated patients

BackgroundSedation of intensive care patients is necessary for comfort and to implement appropriate treatment. The trend of sedation has gone from deep to light sedation. The topic is of interest to intensive care nursing because patients are generally more awake, which requires a different clinical approach than caring for deeply sedated patients.PurposeThe aim of this study was to describe intensive care unit (ICU) nurses experiences of caring for patients who are lightly sedated during mechanical ventilation.MethodsA qualitative approach was used. Semi-structured interviews with nine intensive care nurses were conducted. The interview texts were subjected to qualitative content analysis, resulting in the formulation of one main category and six sub-categories.FindingsThe nurses’ experience of lightly sedated patients was described as a challenge requiring knowledge and experience. The ability to communicate with the lightly sedated patient is perceived as important for ICU nurses. Individualised nursing care respecting the patients’ integrity, involvement and participation are goals in intensive care, but might be easier to achieve when the patients are lightly sedated.ConclusionThe results reinforce the importance of communication in nursing care. It is difficult however to create an inter-personal relationship, encourage patient involvement, and maintain communication with deeply sedated patients. When patients are lightly sedated, the nurses are able to communicate, establish a relationship and provide individualised care. This is a challenge requiring expertise and patience from the nurses. Accomplishing this increases the nurses satisfaction with their care. The positive outcome for the patients is that their experience of their stay in the ICU might become less traumatic.     

Leaving the intensive care unit: a phenomenological study of the patients' experience.

Discharge from intensive care (ICU), is said to pose difficulties for patients; a phenomenon referred to as "relocation stress". However, this phenomenon has not been fully examined, particularly from the critical care patients' perspective. This study, therefore, explored the lived experience of transfer from ICU to the ward. Phenomenology, based on the interpretative Heideggerian approach was used to guide the study. A purposive sample of six participants was selected. Open interviews were used to collect data. Participants were interviewed twice; once in ICU, prior to transfer, and once in the ward following transfer. The findings revealed that pre-transfer, participants were mainly accepting of their impending transfer. Participants discussed a desire for normality and identified that leaving the ICU staff was the most negative component of transfer. In the post-transfer period, findings revealed mixed feelings regarding the actual transfer. Participants were still suffering from physical complaints, which led to feelings of despondency. Differences between ICU and the ward were also highlighted. Finally, the enormity of the ICU experience appeared to have an impact post-transfer. The results of this study indicate that transfer from ICU can be problematic for some individuals. However, caution is required regarding the use of the nursing diagnosis of relocation stress without obtaining an individual perspective on experiences. Recommendations include the need for greater continuity of care for those recovering from critical illness.     

Critical Care Nurses' Experiences: “A Good Relationship with the Patient is a Prerequisite for Successful Pain Relief Management”

There is a lack of studies describing how critical care nurses experience assessing and treating pain in patients receiving postoperative care in an intensive care unit (ICU). The aim of this study was to describe those experiences. Qualitative personal interviews with six critical care nurses in an ICU in northern Sweden were conducted during 2009. The interview texts were subjected to qualitative content analysis, which resulted in the formulation of one theme and four categories. It was important to be able to recognize signs of pain in patients unable to communicate verbally. In older patients, anxiety could be interpreted as an indication of pain. Pain was primarily assessed by means of a visual analog scale. Being unable to treat pain successfully was experienced as failing in one's work. Pharmacologic treatment was always the first choice for relief. The environment was experienced as a hindrance to optimal nursing care, because all postoperative patients shared a room with only curtains between them. The work of assessing and treating pain in patients receiving postoperative care is an important and frequent task for critical care nurses, and knowledge in the field is essential if the patients are to receive optimal nursing care and treatment. Patients cared for in an ICU might benefit from nonpharmacologic treatment. Being without pain after surgery implies increased well-being and shorter hospitalization for the patient.     

The cardiac surgical patient's expectations and experiences of nursing care in the intensive care unit.

There is an abundance of research investigating patient satisfaction. However, few studies have addressed patient satisfaction by comparing patients' expectations of nursing care with the care they actually received. This qualitative study explores both cardiac surgical patients' preconceptions and expectations of nursing care in the intensive care unit (ICU) and their actual experience of nursing care while in the unit. Data were collected using a semistructured interview technique. Interviews took place prior to admission and following discharge from ICU, and were taped and transcribed. Using thematic analysis, major and minor themes emerged from the data. The preoperative interviews revealed that participants had clear expectations of the nurse's role in ICU. They expected the nurse who cared for them to be capable, intelligent, experienced and technically adept. Further, they wanted a nurse who would be vigilant and provide them with personalised care. Participants understood they would be vulnerable and looked to the nurse to help them through this period. Post-operative interviews revealed that when participants perceived vigilance or experienced personalised care from the nurses they felt reassured and secure. However, patients also described feelings of anxiety, apprehension, fear and other unexpected experiences, notably confusion and hallucinations. Recommendations suggest that modification to pre-operative patient education programs could lead to a reduction in anxiety in the post-operative period. They also highlight the importance, to the patients, of nurse caring activities. In addition, the findings suggest a need for staff education that addresses patient anxiety and post-operative psychological disturbances.     

Performance obstacles of intensive care nurses

BACKGROUND: The work environment of intensive care nurses may have substantial impact on both nursing outcomes and patient safety. The factors in a nurse's immediate work environment, in the local work context, have not been studied in detail to provide useful, specific information for work redesign efforts to improve nurse's work and patient safety. Performance obstacles are the factors that hinder intensive care nurses' capacity to perform their jobs and that are associated closely with their immediate work environment. OBJECTIVES: To identify the performance obstacles experienced by intensive care nurses in their work environment. METHODS: A multisite, cross-sectional study was conducted. Data were collected using a 36-item questionnaire and analyzed using univariate statistical analysis. The frequencies of performance obstacles reported by intensive care nurses were computed. RESULTS: Nurses (n = 272) from 17 intensive care units (ICUs) of seven hospitals in Wisconsin participated in the study. The most frequently experienced performance obstacles included noisy work environment (46%), distractions from families (42%), hectic (40%) and crowded work environments (37%), delay in getting medications from pharmacy (36%), spending considerable amount of time teaching families (34%), equipment not being available-someone else using it (32%), patient rooms not well-stocked (32%), insufficient workspace for completing paperwork (26%), seeking for supplies (24%) or patients' charts (23%), receiving many phone calls from families (23%), delay in seeing new medical orders (21%), and misplaced equipment (20%). DISCUSSION: Intensive care nurses experience a variety of performance obstacles in their work environment. Future research should investigate the impact of various performance obstacles on nursing workload, nursing quality of working life, and quality and safety of care, as well as the impact of interventions aimed at redesigning the work system of ICU nurses to remove performance obstacles.     

Nursing Staff Stress and Individual Characteristics in Relation to the Ward Atmosphere in Psychiatric In-Patient Wards

This study investigated the interplay between nursing staff stress, Mastery, Moral Sensitivity, individual characteristics and the ward atmosphere in psychiatric in-patient care. Data were collected through five questionnaires from 93 nursing staff. Multivariate analysis showed that Moral Strength, Moral Burden, Internal Demands, Perceived Stress and age were related to several factors of the ward atmosphere. We conclude that efforts to reduce stress levels and create a supporting ethical climate on psychiatric wards would be beneficial for both psychiatric nursing staff and their nursing practice.     

对ICU患者实施动态人文关怀护理的方法及效果

目的 探讨对ICU住院患者实施人文关怀护理的方法及效果。 方法 2012年1月-2015年12月ICU逐步实施针对性的人文关怀措施并持续动态改进。统计2012~2015年ICU护理不良事件发生情况、患者满意度及护理人员职业认同情况。 结果 2012~2015年ICU患者护理不良事件由40例下降至17例;患者住院满意度由70.4%上升至96.8%;ICU护理人员职业认同感在自我效力感、有意义感、自己决定感维度得分提高。结论 对ICU住院患者实施动态人文关怀护理,可以减少护理不良事件的发生,提高ICU患者的住院满意度,同时提升ICU护理人员的职业认同感。     

What makes a good intensive care unit: a nursing perspective.

With the high prevalence of nursing shortages and low staff retention rates in many Australian intensive care units (ICUs), we aimed to determine what factors were important to nurses working in an ICU. Of all the nursing specialties in New South Wales, intensive care was reported to have had the fifth highest vacancy rate from June 2000-January 2001. A questionnaire was distributed to 36 nurses in a major metropolitan ICU. The response rate was 32 (89 per cent). The ICU has had high staff retention rates and low vacancy rates for a number of years. We were interested to document what factors made this unit a popular one to work in. Factors that were of greatest importance to most nurses were those that dealt with nursing unit management and medical staff. Other factors that rated highly included the ability to self-roster, some aspects of working relationships and having an active role in patient care issues. The survey informed us that nurses at this study site were mostly satisfied with these aspects. Previous studies have demonstrated a strong correlation between job satisfaction and turnover rates amongst nurses. The results of this study highlight the importance of good nursing management and various aspects of the nursing role in attaining job satisfaction in the workplace. These key factors play an important role in achieving high staff retention and low vacancy rates.     

Knowledge and Attitudes Regarding Neonatal Pain Among Nursing Staff of Pediatric Department: An Indian Experience

Neonates receiving care in intensive care units are highly likely to experience pain due to investigations and/or treatments carried out by the health care providers. Neonates are a vulnerable population because they are unable to vocalize their pain. Unaddressed and mismanaged pain can not only affect the child’s comfort, but also may alter the development and cognitive abilities of the child in a later part of his/her life. Therefore it is entirely the caregiver’s responsibility to accurately assess and manage neonatal pain. We assessed and compared the knowledge and attitudes regarding neonatal pain among the nurses posted in the various units of a pediatric department [pediatric ward, pediatric intensive care unit (PICU) and neonatal intensive care unit (NICU)]. An appropriately modified Knowledge and Attitudes Survey Regarding Pain questionnaire was consensually validated, pretested, and then administered to the nursing staff of the pediatric department at a department at a hospital in Gujarat. Data were entered in Epi-Info and analyzed with the use of SPSS 14.0. The questionnaire was administered to 41 nurses working in the Department of Pediatrics, and the response rate was 97.5%. Mean age of the nurses in the study sample was 25.75 years (SD 5.513). The mean total score of the participants was 8.75 out of 17 (SD 2.549), which was unsatisfactory. The mean correct answer rate was 49.67% among the staff of NICU and 48.67% among the pediatric ward and PICU staff. The attitudes among the nurses were assessed. It was concluded that the nurses lack knowledge and that their attitudes also were hindering pain management. One of the barriers identified by the nurses was that physicians do not prescribe analgesics for managing neonatal pain. So not only the nursing staff, but all of the caregivers involved in neonatal care may be lacking in knowledge and hold perceptions and attitudes that hamper neonatal pain management.