Evaluating the Health of the Work Environment and the Perception of New Nurses During the Transition to Practice in Critical Care.

BACKGROUND: New nurses are the major source of hiring for most hospitals. They fill vacancies left by seasoned nurses creating an experience-complexity gap. Turnover among new-graduate nurses is as high as 85% in the first 2 years. OBJECTIVES: The purpose of this study was to provide a deeper understanding of the factors contributing to turnover. The specific aims were (1) to better understand novice nurses' perceptions of their transition to critical-care practice and (2) to describe all eligible critical-care nurses' perceptions of a healthy work environment. METHODS: A quantitative descriptive design was used. Data were collected over 3 weeks in February 2022 from novice nurses (n = 12) who completed the Casey-Fink Nurse Experience Survey and from novice and experienced nurses (n = 47) who completed the American Association of Critical-Care Nurses' Healthy Work Environment Assessment Tool. Data were analyzed using descriptive statistics. RESULTS: Respondents to the Casey-Fink Nurse Experience Survey (n = 12) indicated feeling well supported by family, friends, and preceptors, although they felt less positive about prioritizing care, organizing patient needs, and recommending changes to the plan of care. The overall mean score on the Health Work Environment Assessment Tool was 2.99 (n = 47), indicating the need for improvement. Responses varied by unit, years of experience, and certification status. CONCLUSION: This study contributes to the evolving body of nursing knowledge and has provided a more detailed understanding of the health of the work environment and perceptions of new nurses during the transition to practice.

A National Survey of Stress and Burnout in Critical Care Nurses: A Prepandemic Study.

BACKGROUND: Critical care nurses (CCNs) experience a higher level of stress and burnout than nurses in other specialties. Approximately 50% of CCNs are mildly stressed, and almost 20% are moderately stressed. Prolonged periods of stress can lead to burnout, which has been shown to have deleterious effects on quality and patient safety. OBJECTIVES: The purpose of this study is to determine the prevalence of burnout among a national sample of CCNs and the association with environmental factors. METHODS: A national survey of CCNs working in the United States was implemented using an exploratory descriptive design. The anonymous survey was developed iteratively according to best practices of survey design. The survey included the Perceived Stress Scale and the Copenhagen Burnout Inventory tool. Pretesting and pilot testing were conducted with CCN specialists, and the survey was revised based on their feedback. An anonymous link was distributed to respondents using convenience sampling through social media and further disseminated via snowball sampling. RESULTS: Two hundred seventy nurses responded to the survey. The mean (SD) Perceived Stress Scale score in the study population was 18.5 (6.4), indicating moderate stress. The mean (SD) Copenhagen Burnout Inventory score was 61.9 (16.5), indicating moderate burnout. Our study found that the overall health of the work environment was one of the most important factors associated with both stress and burnout. CONCLUSIONS: This study has demonstrated the relationship between the health of the work environment and burnout among CCNs. It is imperative that health care organizations evaluate and implement strategies to optimize the health of the work environment to mitigate burnout and its negative sequelae on the nurse, patient, and system.

Outcomes of In-hospital Cardiac Arrest: A Review of the Evidence.

Cardiac arrest is a significant cause of morbidity and mortality in the United States. Cardiac arrest can occur in the community or among hospitalized patients. There are many commonalities between in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest; however, significant differences exist. Optimizing outcomes for patients with IHCA depends on high-quality care supported by the best available evidence. It is essential that critical care nurses are familiar with the evidence related to IHCA. This article focuses on a review of the evidence on IHCA, focusing on practical implications for critical care nursing practice.

Improving the Accuracy of Delirium Assessments in Neuroscience Patients: Scaling a Quality Improvement Program to Improve Nurses' Skill, Compliance, and Accuracy in the Use of the Confusion Assessment Method in the Intensive Care Unit Tool.

BACKGROUND: Delirium affects up to 80% of critically ill patients; however, many cases of delirium go unrecognized because of inaccurate assessments. The effectiveness of interventions to improve assessment accuracy among the general population has been established, but assessments among neuroscience patients are uniquely complicated due to the presence of structural neurologic changes. OBJECTIVES: The purposes of this quality improvement project were to improve the accuracy of nurse's delirium assessments among neuroscience patients and to determine the comparative effectiveness of the intervention between medical and neuroscience patients. METHODS: A multifaceted nurse-led intervention was implemented, and a retrospective analysis of preintervention and postintervention data on assessment accuracy was completed. Results were stratified by population, level of sedation, and level of care. Differences were analyzed using Fisher exact test. RESULTS: Data from 1052 delirium assessments were analyzed and demonstrated improvement in assessment accuracy from 56.82% to 95.07% among all patients and from 29.79% to 92.98% among sedate or agitated patients. Although baseline accuracy was significantly lower among neuroscience patients versus medical intensive care unit patients, no significant differences in postintervention accuracy were noted between groups. CONCLUSION: Results from this project demonstrate the effectiveness of the nurse-led intervention among neuroscience patients. Future research is needed to explore the effectiveness of this nurse-led intervention across other institutions and to describe the effectiveness of new interventions to improve outcomes at the patient and organizational levels.

Standard work for room entry: Linking lean, hand hygiene, and patient-centeredness.

BACKGROUND: Healthcare-associated infections are costly and fatal. Substantial front-line, administrative, regulatory, and research efforts have focused on improving hand hygiene. PROBLEM: While broad agreement exists that hand hygiene is the most important single approach to infection prevention, compliance with hand hygiene is typically only about 40%(1). GOALS: Our aim was to develop a standard process for room entry in the intensive care unit that improved compliance with hand hygiene and allowed for maximum efficiency. STRATEGY: We recognized that hand hygiene is a single step in a substantially more complicated process of room entry. We applied Lean engineering techniques to develop a standard process that included both physical steps and also standard communication elements from provider to patients and families and created a physical environment to support this. RESULTS: We observed meaningful improvement in the performance of the new standard as well as time savings for clinical providers with each room entry. We also observed an increase in room entries that included verbal communication and an explanation of what the clinician was entering the room to do. IMPLICATIONS: The design and implementation of a standardized room entry process and the creation of an environment that supports that new process has resulted in measurable positive outcomes on the medical intensive care unit, including quality, patient experience, efficiency, and staff satisfaction. Designing a process, rather than viewing tasks that need to happen in close proximity in time (either serially or in parallel) as unrelated, simplifies work for staff and results in higher compliance to individual tasks.

An Innovative Approach to Improving the Accuracy of Delirium Assessments Using the Confusion Assessment Method for the Intensive Care Unit.

BACKGROUND: Delirium occurs in up to 80% of intensive care unit (ICU) patients. Despite its prevalence in this population, there continues to be inaccuracies in delirium assessments. In the absence of accurate delirium assessments, delirium in critically ill ICU patients will remain unrecognized and will lead to negative clinical and organizational outcomes. OBJECTIVES: The goal of this quality improvement project was to facilitate sustained improvement in the accuracy of delirium assessments among all ICU patients including those who were sedate or agitated. METHODS: A pretest-posttest design was used to evaluate the effectiveness of a program to improve the accuracy of delirium screenings among patients admitted to a medical ICU or coronary care unit. RESULTS: Two hundred thirty-six delirium assessment audits were completed during the baseline period and 535 during the postintervention period. Compliance with performing at least 1 delirium assessment every shift was 85% at baseline and improved to 99% during the postintervention period. Baseline assessment accuracy was 70.31% among all patients and 53.49% among sedate and agitated patients. Postintervention assessment accuracy improved to 95.51% for all patients and 89.23% among sedate and agitated patients. CONCLUSION: The results from this project suggest the effectiveness of the program in improving assessment accuracy among difficult-to-assess patients. Further research is needed to demonstrate the effectiveness of this model across other critical care units, patient populations, and organizations.

Improving Accuracy of Cardiac Electrode Placement: Outcomes of Clinical Nurse Specialist Practice.

PURPOSE: The purpose of this quality improvement project was to facilitate a sustainable improvement in the accuracy of cardiac electrode placement for continuous bedside monitoring in intensive care unit patients. BACKGROUND: Continuous cardiac electrocardiograph monitoring is a standard of practice in critical care areas and is essential to accurate interpretation of cardiac dysrhythmias and early detection of myocardial ischemia. Accurate assessment of electrocardiographs depends on precise placement of electrodes; however, electrodes are often placed inaccurately. RATIONALE: Evaluation of baseline practice revealed that cardiac electrodes were placed correctly in only 12.5% of patients. The most frequently misplaced electrode was the V lead, followed by lower limb leads. DESCRIPTION: This project was conducted between July 1, 2013, and October 31, 2013, and involved a multifaceted education program for registered nurse and patient care technician staff on the physiologic basis and technical procedures for cardiac electrode placement. The clinical nurse specialist served as an informal leader, role model, and mentor by developing and empowering unit champions to perform real-time auditing and provide real-time feedback to colleagues. OUTCOME: At 3 months after intervention, the accuracy of cardiac electrode placement was sustained at greater than 85%, representing a 6-fold improvement above the preintervention baseline. CONCLUSION: Sustainable improvement in quality requires creation of a culture that supports quality improvement initiatives. As experts in clinical practice, evidence-based practice, and leadership, clinical nurse specialists are optimally positioned to function as change agents whose initiatives measurably improve outcomes. IMPLICATIONS: This quality improvement project serves as a model for improving accuracy of cardiac electrode placement at the nursing staff level. Future research is necessary to improve outcomes related to accuracy of cardiac electrode placement on the patient and systems levels.

AACN CSI Academy, part 3: Introducing the Massachusetts CSI Nursing Delirium Collaborative.

In the final installment of our three-part series, we reveal how the Boston cohort of the American Association of Critical-Care Nurses (AACN) Clinical Scene Investigator (CSI) Academy launched a collective to improve patient safety and quality outcomes related to delirium.

Withholding or continuing enteral feedings during repositioning and the incidence of aspiration.

BACKGROUND: Withholding enteral feedings during repositioning is based on tradition, but available evidence does not support this practice. Although research indicates that withholding of enteral feedings during repositioning contributes to undernourishment, the relationship between continuing enteral feedings during repositioning and the incidence of aspiration has not been determined. OBJECTIVE: To determine the feasibility of a study designed to explore differences in the incidence of aspiration when enteral feedings are withheld or continued during repositioning. METHODS: A crossover design with a convenience sample from 3 medical and 3 surgical intensive care units was used. Two sample sets of subglottal secretions were collected from each patient, once when enteral feedings were withheld during repositioning and once when enteral feedings were continued during the change in position. The incidence of aspiration was assessed by testing specimens for the presence of pepsin. RESULTS: Sublgottal secretions were collected from 23 patients (n = 46 with crossover design). Aspiration during repositioning occurred in 2 patients when enteral feedings were withheld and in 2 patients when feedings were continued during repositioning. According to the McNemar test, the incidence of aspiration when enteral feedings were withheld did not differ significantly from the incidence when the feedings were continued during repositioning (P = .88). CONCLUSIONS: A research protocol to directly explore the relationship between the incidence of aspiration and withholding or continuing enteral feedings during repositioning is feasible.