Incidence, characteristics, and associated factors of pressure injuries acquired in intensive care units over a 12-month period: A secondary analysis of a quality improvement project.

OBJECTIVES: To determine the 12-month cumulative incidence, characteristics, and associated factors of pressure injuries acquired in Intensive Care Units. SETTING: Four intensive care units in a Norwegian University Hospital. RESEARCH METHODOLOGY: A prospective observational cohort study using data from daily skin inspections during a quality improvement project. We used descriptive statistics and logistic regression. Variables associated with the development of intensive care unit-acquired pressure injuries are presented with odds ratios (OR), and 95% confidence intervals. RESULTS: The 12-month cumulative incidence of patients (N = 594) developing intensive care unit-acquired pressure injuries was 29 % (172/594) for all categories and 16 % (95/594) when excluding category I pressure injuries (no skin loss). Cumulative incidence for patients acquiring medical device-related pressure injuries was 15 % (91/594) and 11 % (64/594) for category II or worse. Compression stockings (n = 51) and nasogastric tubes (n = 22) were the most frequent documented medical devices related to pressure injuries. Development of pressure injuries category II or worse was significantly associated with vasoactive drug infusions (OR 11.84, 95 % CI [1.59; 88.13]) and longer intensive care unit length of stay (OR 1.06, 95 % CI [1.04; 1.08]). CONCLUSION: The 12-month cumulative incidence of intensive care unit-acquired pressure injuries was relatively high when category I pressure injuries were included, but comparable to other studies when category I was excluded. Some medical device-related pressure injuries were surprisingly frequent, and these may be prevented. However, associated factors of developing pressure injuries were present and deemed non-modifiable. IMPLICATIONS FOR CLINICAL PRACTICE: Awareness about pressure injury prevention is needed in the intensive care unit considering high incidences. Nurses can detect category I pressure injuries early, which may be reversed. Our findings show several factors that clinicians can control to reduce the risk of pressure injuries in the intensive care unit.

Prevalence of psychological distress in nurses, physicians and leaders working in intensive care units during the COVID-19 pandemic: a national one-year follow-up study.

OBJECTIVE: To report and compare psychological distress as symptoms of anxiety, depression and post-traumatic stress among intensive care units' (ICU) nurses, physicians and leaders at 12 months after the baseline survey (spring 2020), during the COVID-19 pandemic in Norway. Furthermore, to analyse which baseline demographic and COVID ICU-related factors have a significant impact on psychological distress at 12 months. DESIGN: Prospective, longitudinal, observational cohort study. SETTING: Nationwide, 27 of 28 hospitals with COVID ICUs in Norway. PARTICIPANTS: Nurses, physicians and their leaders. At 12 month follow-up 287 (59.3%) of 484 baseline participants responded. PRIMARY AND SECONDARY OUTCOME MEASURES: Symptoms of anxiety and depression using the Hopkins Symptoms Checklist-10 (HSCL-10). Symptoms of post-traumatic stress using the post-traumatic stress disease checklist for the Diagnostic and Statistical Manual of Mental Disorders 5 (PCL-5).Demographics (included previous symptoms of anxiety and depression) and COVID ICU-related factors (professional preparations, emotional experience and support) impacting distress at 12 months. RESULTS: Psychological distress, defined as caseness on either or both HSCL-10 and PCL-5, did not change significantly and was present for 13.6% of the participants at baseline and 13.2% at 12 month follow-up. Nurses reported significantly higher levels of psychological distress than physicians and leaders. Adjusted for demographics and the COVID ICU-related factors at baseline, previous symptoms of depression and fear of infection were significantly associated with higher levels of anxiety and depression at 12 months. Previous symptoms of depression, fear of infection and feeling of loneliness was significantly associated with more symptoms of post-traumatic stress. CONCLUSION: One year into the COVID-19 pandemic 13.2% of the ICUs professionals reported psychological distress, more frequently among the nurses. Fear of infection, loneliness and previous symptoms of depression reported at baseline were associated with higher levels of distress. Protective equipment and peer support are recommended to mitigate distress. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov. Identifier: NCT04372056.

Combining clinical practice and education in critical care nursing-A trainee program for registered nurses.

AIM: The aim of this study was to describe the experiences of a master's-level critical care nursing program for trainees in postoperative and intensive care units. DESIGN: An exploratory design with a multidimensional approach was chosen. METHODS: The study was conducted from 2018 to 2019 at a university hospital in southern Norway in collaboration with a university college of nursing. Data were collected through seven focus group interviews with trainees, preceptors, heads of departments, clinical nurse educators and professors (n = 26). The thematic analysis progressed from description to a deeper understanding, searching for manifest and latent patterns across the data. The COREQ checklist was used for reporting the study. RESULTS: The analysis resulted in one overarching theme: 'To walk the critical care nursing pathway - balancing competency, time, and challenges to become proficient'. The subthemes were 'expectations, obligations, and workload in unknown environments', 'constantly assessing while being assessed', 'continuous precepting and challenges', 'vulnerability and commitment' and 'thriving in the role, mastering new skills'. The study provides valuable insights into a complex learning environment and the importance of caring aspects for trainees during their critical care nursing education. CONCLUSION: Precepting, continuous competence assessment and clear learning outcomes are necessary to create a safe environment for the trainees during their development. IMPLICATIONS FOR THE PROFESSION: The results advocate investing in inexperienced trainees' competency development to become proficient, creating a safe learning environment in a highly complex setting. This may also, as previous studies suggest, increase staff retention.

Documentation for Assessing Pain in Postoperative Pain Management Pre- and Post-intervention.

PURPOSE: Although Norwegian law requires the documentation of patients' care processes, including pain assessment, research has shown that the quality of postoperative documentation for assessing pain does not meet an acceptable standard and requires improvement. The purpose of this study was to investigate whether an educational intervention can increase nurses' documentation of postoperative pain assessments, alter patients' opioid consumption, and ensure that patients have at least one documented Numeric Rating Scale (NRS) ≤3 at rest before being discharged. A secondary aim was to investigate whether the nurses' education and experience influenced their pain assessments. DESIGN: An observational study with a pre-post intervention. METHODS: The study following a pre-post design involved documenting pain assessments of 304 patients undergoing cancer surgeries in a postoperative unit at the Norwegian Radium Hospital, Oslo University Hospital. In an educational intervention, two 45-minutes teaching sessions within two weeks, addressed validated pain assessment tools and the documentation of pain assessment. Descriptive frequency analysis and partial correlation with Pearson's r - value were used, with P < .05 indicating significance. FINDINGS: Postintervention, pain assessments in general increased significantly from a mean of two times per patient to three times. Overall, the use of assessment tool Critical -Care Pain Observation Tool increased from 6.1% to 25.8%, opioid consumption increased in mean from 3.34 to 4.79 in milligram and the documentation at discharge increased from 81.4% to 91.4%. The documentation of nurses with more than 10 years' experience in the unit especially improved from 17.5% to 31.7%. CONCLUSIONS: Educational intervention and reminders about basic systematic pain assessment and the evaluation of pain measures improved nurses' documentation of postoperative pain management and documentation at discharge. The findings underscore the importance of regularly ensuring the quality of patients' treatment by systematically documenting nurses' clinical tasks and the outcome of patients' care.

Patient mobilisation in the intensive care unit and evaluation of a multifaceted intervention including Facebook groups: A quasi-experimental study.

AIMS: To describe prevalence and time to mobilisation in intensive care unit patients defined as a minimum sitting in an upright position in bed, and evaluate the impact of a multifaceted quality improvement campaign on likelihood of patients being mobilised. RESEARCH METHODOLOGY/DESIGN: Quality improvement project using a quasi-experimental study design, comparing patient cohorts before (Before) and after (Intervention) a campaign including educational sessions, audit and feedback of intensive care unit quality indicators via closed Facebook-groups and e-mail and local opinion leaders. Secondary analysis of mobilisation data from adult intensive care patient stays extracted from electronical medical charts. Likelihood of being mobilised was analysed with Multivariate Cox-regression model and reported as Sub-hazard Ratio (SHR). SETTING: Four intensive care units in a university hospital. MAIN OUTCOME MEASURES: Prevalence and time to first documented mobilisation, defined as at least "sitting in bed" during the intensive care unit stay. RESULTS: Overall, 929 patients were analysed, of whom 710 (76 %) were mobilised; 73 % (356/ 489) in Before vs 81 % (354/ 440) in Intervention (p = 0.007). Median time to mobilisation was 69.9 (IQR: 30.0, 149.8) hours; 71.7 (33.9, 157.9) in Before and 66.0 (27.1, 140.3) in Intervention (p = 0.104). Higher SAPS II-scores were associated with lower likelihood (SHR 0.98, 95 % CI 0.97-0.99), whereas admissions due to gastroenterological failure (SHR 2.1, 95 % CI 1.4-3.0), neurological failure (SHR 1.5, 95 % CI 1.0-2.2) and other causes (intoxication, postoperative care, haematological-, and kidney failure) (SHR 1.7, 95 % CI 1.13-2.6) were associated with higher likelihood of mobilisation vs respiratory failure. CONCLUSION: A quality improvement campaign including use of Facebook groups is feasible and may improve mobilisation in intensive care unit patients. Most patients were mobilised within 72 hours following intensive care unit admission, and SAPS II scores and causes for intensive care unit admission were both associated with likelihood of being mobilised.

Correction: Stafseth et al. Symptoms of Anxiety, Depression, and Post-Traumatic Stress Disorder in Health Care Personnel in Norwegian ICUs during the First Wave of the COVID-19 Pandemic, a Prospective, Observational Cross-Sectional Study. Int. J. Environ. Res. Public Health 2022, 19, 7010.

In the original publication [...].

Symptoms of Anxiety, Depression, and Post-Traumatic Stress Disorder in Health Care Personnel in Norwegian ICUs during the First Wave of the COVID-19 Pandemic, a Prospective, Observational Cross-Sectional Study.

Background: The COVID-19 pandemic has induced demanding work situations in intensive care units (ICU). The objective of our study was to survey psychological reactions, the disturbance of social life, work effort, and support in ICU nurses, physicians, and leaders. Methods: From May to July 2020, this cross-sectional study included 484 ICU professionals from 27 hospitals throughout Norway. Symptoms of anxiety and depression were measured on Hopkins Symptom Checklist-10 (HSCL-10). Symptoms of post-traumatic stress disorder (PTSD) were measured on the PCL-5. Results: The study population were highly educated and experienced professionals, well prepared for working with COVID-ICU patients. However, 53% felt socially isolated and 67% reported a fear of infecting others. Probable cases of anxiety and depression were found in 12.5% of the registered nurses, 11.6% of the physicians, and 4.1% of the leaders. Younger age and <5 years previous work experiences were predictors for high HSCL-10 scores. Reported symptom-defined PTSD for nurses 7.1%; the leaders, 4.1%; and 2.3% of physicians. Conclusions: ICU health care professionals experienced talking with colleagues as the most helpful source of support. The COVID-ICU leaders reported a significantly higher mean score than physicians and nurses in terms of pushing themselves toward producing high work effort.

Healthcare professionals in COVID-19-intensive care units in Norway: preparedness and working conditions: a cohort study.

OBJECTIVE: To survey the healthcare professionals' background and experiences from work with patients with COVID-19 in intensive care units (ICUs) during the first wave of the COVID-19 pandemic in Norway. DESIGN: Observational cohort study. SETTING: COVID-ICUs in 27 hospitals across Norway. PARTICIPANTS: Healthcare professionals (n=484): nurses (81%), medical doctors (9%) and leaders (10%), who responded to a secured, web-based questionnaire from 6 May 2020 to 15 July 2020. PRIMARY AND SECONDARY MEASURES: Healthcare professionals': (1) professional and psychological preparedness to start working in COVID-ICUs, (2) factors associated with high degree of preparedness and (3) experience of working conditions. RESULTS: The age of the respondents was 44.8±10 year (mean±SD), 78% were females, 92% had previous ICU working experience. A majority of the respondents reported professional (81%) and psychological (74%) preparedness for working in COVID-ICU. Factors significantly associated with high professional preparedness for working in COVID-19-ICU in a multivariate logistic model were previous ICU work experience (p<0.001) and participation in COVID-ICU simulation team training (p<0.001). High psychological preparedness was associated with higher age (p=0.003), living with spouse or partner (p=0.013), previous ICU work experience (p=0.042) and participation in COVID-ICU simulation team training (p=0.001). Working with new colleagues and new professional challenges were perceived as positive in a majority of the respondents, whereas 84% felt communication with coworkers to be challenging, 46% were afraid of being infected and 82% felt discomfort in denying access for patient relatives to the unit. Symptoms of sweating, tiredness, dehydration, headache, hunger, insecurity, mask irritation and delayed toilet visits were each reported by more than 50%. CONCLUSIONS: Healthcare professionals working during the first wave of COVID-ICU patients in Norway were qualified and prepared, but challenges and potential targets for future improvements were present. TRIAL REGISTRATION NUMBER: NCT04372056.

Testing the Reliability and Validity of the Nursing Activities Score in Critical Care Nursing.

BACKGROUND AND PURPOSE: The purpose of this study was to test the reliability and validity of the conceptual model of critical care nursing using the Nursing Activities Score (NAS) for intensive care unit (ICU) patients. METHODS: An observational study conducted in 2011 using the NAS scores of 219 patients in Norway. The inter-rater reliability (IRR) was tested by parallel classifications. The validity was explored by an exploratory factor analysis (EFA) and a confirmatory factor analysis (CFA) as the measurement models in the structural equation model. RESULTS: Within the paired ratings the Spearman's correlation coefficient was 0.39. The EFA results explained 77% of the variance with six factors. The reduced CFA model resulted in a three-factor model: relationship, prevention and treatment. CONCLUSION: The findings supported the IRR and construct validity of the conceptual model of the NAS.

Validation of the nursing workload scoring systems "Nursing Activities Score" (NAS), and "Therapeutic Intervention Scoring System for Critically Ill Children" (TISS-C) in a Greek Paediatric Intensive Care Unit.

OBJECTIVES: To assess the reliability and validity of the Greek version of Nursing Activities Score (NAS), and Therapeutic Intervention Scoring System for Critically Ill Children (TISS-C) in a Greek Paediatric Intensive Care Unit (PICU). RESEARCH METHODOLOGY: A methodological study was performed in one PICU of the largest Paediatric Hospital in Athens-Greece. The culturally adapted and validated Greek NAS version, enriched according to the Norwegian paediatric one (P-NAS), was used. TISS-C and Norwegian paediatric interventions were translated to Greek language and backwards. Therapeutic Intervention Scoring System (TISS-28) was used as a gold standard. Two independent observers simultaneously recorded 30 daily P-NAS and TISS-C records. Totally, 188 daily P-NAS, TISS-C and TISS-28 reports in a sample of 29 patients have been obtained during five weeks. Descriptive statistics, reliability and validity measures were applied using SPSS (ver 22.0) (p ≤ 0.05). RESULTS: Kappa was 0.963 for P-NAS and 0.9895 for TISS-C (p < 0.001) and Intraclass Correlation Coefficient for all scale items of TISS-C was 1.00 (p < 0.001). P-NAS, TISS-28 and TISS-C measurements were significantly correlated (0.680 ≤ rho ≤ 0.743, p < 0.001). The mean score(±SD) for TISS-28, P-NAS and TISS-C was 23.05(±5.72), 58.14(±13.98) and 20.21(±9.66) respectively. CONCLUSION: These results support the validity of P-NAS and TISS-C scales to be used in greek PICUs.

Association between patient classification systems and nurse staffing costs in intensive care units: An exploratory study.

OBJECTIVES: Nurse staffing costs represent approximately 60% of total intensive care unit costs. In order to analyse resource allocation in intensive care, we examined the association between nurse staffing costs and two patient classification systems: the nursing activities score (NAS) and nine equivalents of nursing manpower use score (NEMS). RESEARCH METHODOLOGY/DESIGN: A retrospective descriptive correlational analysis of nurse staffing costs and data of 6390 patients extracted from a data warehouse. SETTING: Three intensive care units in a university hospital and one in a regional hospital in Norway. MAIN OUTCOME MEASURES: Nurse staffing costs, NAS and NEMS. RESULTS: For merged data from all units, the NAS was more strongly correlated with monthly nurse staffing costs than was the NEMS. On separate analyses of each ICU, correlations were present for the NAS on basic costs and external overtime costs but were not significant. The annual mean nurse staffing cost for 1% of NAS was 20.9-23.1 euros in the units, which was comparable to 53.3-81.5 euros for 1 NEMS point. CONCLUSION: A significant association was found between monthly costs, NAS, and NEMS. Cost of care should be based on individual patients' nursing care needs. The NAS makes nurses' workload visible and may be a helpful classification system in future planning and budgeting of intensive care resources.

The experiences of nurses implementing the Modified Early Warning Score and a 24-hour on-call Mobile Intensive Care Nurse: An exploratory study.

AIMS AND OBJECTIVES: To explore experiences of nurses implementing and using the Modified Early Warning Score (MEWS) and a Mobile Intensive Care Nurse (MICN) providing 24-hour on-call nursing support. BACKGROUND: To secure patient safety in hospital wards, nurses may increase the quality of care using a tool to detect the failure of vital functions. Possibilities for support can be provided through on-call supervision from a qualified team or nurse. DESIGN: This exploratory qualitative investigation used focus group interviews with nurses from two wards of a university hospital in Norway. METHODS: A purposive sample of seven registered nurses was interviewed in focus groups. A semi-structured guide and an inductive thematic analysis were used to identify interview themes. RESULTS: Three themes emerged: (1) experiences with the early recognition of deterioration using the MEWS, (2) supportive collaboration and knowledge transfer between nurses and (3) a "new" precise language using the score for communicating with physicians. The use of scores and support were perceived as improving care for deteriorating patients and for supporting the collaboration of nurses with other professionals. CONCLUSION: In our study, nurses described increased confidence in the recognition of deteriorating patients and in the management of such situations. The non-critical attitude, supportive communication and interactive learning according to the MICN were essential elements for success.

Nursing Activities Score: an updated guideline for its application in the Intensive Care Unit / Nursing activities score: manual atualizado para aplicação em Unidade de Terapia Intensiva / Nursing activities score: manual actualizado para su aplicación en la Unidade de Cuidados Críticos

ABSTRACT Objective To describe nursing workload in Intensive Care Units (ICU) in different countries according to the scores obtained with Nursing Activities Score (NAS) and to verify the agreement among countries on the NAS guideline interpretation. Method This cross-sectional study considered 1-day measure of NAS (November 2012) obtained from 758 patients in 19 ICUs of seven countries (Norway, the Netherlands, Spain, Poland, Egypt, Greece and Brazil). The Delphi technique was used in expertise meetings and consensus. Results The NAS score was 72.8% in average, ranging from 44.5% (Spain) to 101.8% (Norway). The mean NAS score from Poland, Greece and Egypt was 83.0%, 64.6% and 57.1%, respectively. The NAS score was similar in Brazil (54.0%) and in the Netherlands (51.0%). There were doubts in the understanding of five out 23 items of the NAS (21.7%) which were discussed until researchers’ consensus. Conclusion NAS score were different in the seven countries. Future studies must verify if the fine standardization of the guideline can have a impact on differences in the NAS results.

RESUMO Objetivo Descrever a carga de trabalho de enfermagem em Unidades de Terapia Intensiva (UTI) de diferentes países, segundo o Nursing Activities Score (NAS), e padronizar o manual do NAS para uso nessas Unidades. Método Estudo transversal realizado em 19 UTI de sete países (Noruega, Holanda, Espanha, Polônia, Egito, Grécia e Brasil) com um total de 758 pacientes adultos, em novembro de 2012. Resultados A média do NAS total da amostra foi 72.81%, com variação entre 44.46% (Espanha) e101.81% (Noruega). Nas UTI da Polônia, Grécia e Egito, as médias foram de 83.00%, 64.59% e 57.11%, respectivamente. As médias NAS no Brasil (53.98%) e na Holanda (50,96%) foram similares. Dos 23 itens da escala, houve dúvidas no entendimento de 5(21.74%), que foram solucionados por consenso entre os pesquisadores. Conclusão O estudo mostrou diferentes cargas de trabalho de enfermagem nas UTI estudadas. Um manual padronizado do NAS para uso nessas unidades contribuirá para sanar dúvidas em futuras aplicações.

RESUMEN Objetivo Describir la carga de trabajo de enfermería en Unidades de Cuidados Intensivos (UCI) de diferentes países según el Nursing Activities Score (NAS) y establecer una guía estandarizada para su utilización en UCI. Método estudio observacional en 19 UCIs de siete países (Noruega, Países Bajos, España, Polonia, Egipto, Grecia y Brasil) incluyendo 758 pacientes adultos en Noviembre de 2012. Resultados La puntuación media total en la escala NAS fue de 72.81% com valores entre 44.46% (España) y 101.8% (Noruega). Las medias NAS en Polonia, Grecia y Egipto fue de 83.0%, 64.59% y 57.11% respectivamente. El NAS medio fue similar en Brasil (53.98%) y los Países Bajos (50.96%). De los 23 ítems de la escala hubo problemas en la interpretación de 5 de ellos (21.74%). Este problema se resolvió mediante el consenso entre los investigadores. Conclusión El presente estudio demuestra variación en la carga de trabajo en UCI de diferentes países. La guía estandarizada de puntuación del NAS puede servir como una herramienta para resolver dudas en futuras aplicaciones.

Interrater reliability of Nursing Activities Score among Intensive Care Unit health professionals / Confiabilidade inter observadores do Nursing Activities Score entre profissionais de saúde da Unidade de Terapia Intensiva / Confiabilidad inter-observador del Nursing Activities Score entre profesionales de la salud en una Unidad de Cuidado Intensivo

ABSTRACT Objective To analyze the interrater reliability of NAS among critical care nurses and managers in an ICU. Method This was a methodological study performed in an adult, general ICU in Norway. In a random selection of patients, the NAS was scored on 101 patients by three raters: a critical care nurse, an ICU physician and a nurse manager. Interrater reliability was analyzed by agreement between groups and kappa statistics. Results The mean NAS were 88.4 (SD=16.2) and 88.7 (SD=24.5) respectively for the critical care nurses and nurse managers. A lower mean of 83.7 (SD=21.1) was found for physicians. The 18 medical interventions showed higher agreement between critical care nurses and physicians (85.6%), than between critical care nurses and nurse managers (78.7). In the five nursing activities the Kappa-coefficients were low for all activities in all compared groups. Conclusion The study indicated a satisfactory agreement of nursing workload between critical care nurses and managers.

RESUMO Objetivo Analisar a confiabilidade interobservadores do NAS entre enfermeiros intensivistas e administradores em UTI. Método Estudo metodológico desenvolvido em UTI geral, de adultos, na Noruega. Em uma amostra selecionada, o NAS foi aplicado em 101 pacientes por três avaliadores: enfermeira assistencial, médico intensivista e enfermeira gestora. A confiabilidade interobservadores foi analisada por meio do teste Kappa. Resultados As médias NAS foram 88,4(SD=16,2) e 88,7(SD=24,5) respectivamente para enfermeiros assistenciais e gestores. Os médicos obtiveram média NAS inferior (83,7; SD=21,1). As 18 intervenções médicas tiveram maior concordância entre enfermeiros assistenciais e médicos (85,6), comparativamente aos enfermeiros assistenciais e gestores (78,7). Nas cinco atividades de enfermagem, os coeficientes Kappa foram baixos em todas as atividades e entre todos os grupos. Conclusão O estudo mostrou confiabilidade interobservadores satisfatória para o NAS entre enfermeiros assistenciais e gestores.

RESUMEN Objetivo : Analizar la confiabilidad inter-observador del NAS entre administradores y enfermeras clínicas en la UCI. Método : Estudio metodológico desarrollado en una UCI general en Noruega. En una muestra seleccionada el NAS fue aplicado en 101 pacientes críticos por tres clases de evaluadores: Enfermeras asistenciales, médicos intensivistas y enfermeras gestoras. La confiabilidad inter-observador fue analizada mediante el test de Kappa. Resultados : Los promedios del NAS fueron 88,4(DE=16,2) y 88,7(DE=24,5) respectivamente para las enfermeras asistenciales y gestoras. Los médicos obtuvieron un promedio NAS inferior 83,7;DE=21,1). Las 18 intervenciones médicas tuvierón mayor concordancia entre las enfermeras asistenciales y los médicos (85,6), en comparación con las enfermeras asistenciales y gestoras (78,7). En las cinco actividades de enfermería, los coeficientes Kappa fueron bajos entodas las actividades y entre todos los grupos. Conclusión : El estudio mostró confiabilidad inter-observador satisfactorias para el NAS entre las enfermeras asistenciales y gestoras.

Nursing Activities Score: an updated guideline for its application in the Intensive Care Unit.

Objective To describe nursing workload in Intensive Care Units (ICU) in different countries according to the scores obtained with Nursing Activities Score (NAS) and to verify the agreement among countries on the NAS guideline interpretation. Method This cross-sectional study considered 1-day measure of NAS (November 2012) obtained from 758 patients in 19 ICUs of seven countries (Norway, the Netherlands, Spain, Poland, Egypt, Greece and Brazil). The Delphi technique was used in expertise meetings and consensus. Results The NAS score was 72.8% in average, ranging from 44.5% (Spain) to 101.8% (Norway). The mean NAS score from Poland, Greece and Egypt was 83.0%, 64.6% and 57.1%, respectively. The NAS score was similar in Brazil (54.0%) and in the Netherlands (51.0%). There were doubts in the understanding of five out 23 items of the NAS (21.7%) which were discussed until researchers' consensus. Conclusion NAS score were different in the seven countries. Future studies must verify if the fine standardization of the guideline can have a impact on differences in the NAS results.

Interrater reliability of Nursing Activities Score among Intensive Care Unit health professionals.

Objective To analyze the interrater reliability of NAS among critical care nurses and managers in an ICU. Method This was a methodological study performed in an adult, general ICU in Norway. In a random selection of patients, the NAS was scored on 101 patients by three raters: a critical care nurse, an ICU physician and a nurse manager. Interrater reliability was analyzed by agreement between groups and kappa statistics. Results The mean NAS were 88.4 (SD=16.2) and 88.7 (SD=24.5) respectively for the critical care nurses and nurse managers. A lower mean of 83.7 (SD=21.1) was found for physicians. The 18 medical interventions showed higher agreement between critical care nurses and physicians (85.6%), than between critical care nurses and nurse managers (78.7). In the five nursing activities the Kappa-coefficients were low for all activities in all compared groups. Conclusion The study indicated a satisfactory agreement of nursing workload between critical care nurses and managers.

The characterisation of workloads and nursing staff allocation in intensive care units: a descriptive study using the Nursing Activities Score for the first time in Norway.

OBJECTIVE: This study compares the Nine Equivalents of Nursing Manpower Use Score (NEMS) to the Nursing Activities Score (NAS) in terms of characterising the nursing workload by examining and calculating the per-nurse NAS% over a 24-h period. METHOD: The sample consisted of 235 patients from four volunteered for the study multidisciplinary ICUs in Norway. The daily NEMS, NAS and number of nurses who were involved in patient care per ICU were measured over one month from 2008 to 2009. RESULTS: The average length of stay for the included patients was 5 days, and the mean patient age was 52.8 years. The mean NEMS was 32.7 points (S.D., 8.98 points), and the mean NAS was 96.24% (S.D., 22.35%). Several nurses exhibited mean NEMS points that ranged from 16 to 39.7 per ICU per day. The correlation between the NEMS and NAS could only be separately determined for each ICU. The correlation was r=0.16-0.40 [significant at the 0.01 level (2-tailed)] per unit. Depending on which unit was investigated, each nurse was observed to perform of capacity with a NAS as high as 75-90%. CONCLUSION: The study suggests that the actual numbers of nurses might explain the calculated NAS of 75-90% per nurse.