Advanced Variables to Optimize Hemodynamic Monitoring.

Measuring hemodynamic parameters has become safer and more precise than in the past. Accurately monitoring and evaluating the effectiveness of fluid, inotrope, and vasoactive medication administration can improve patient outcomes. Arbitrary fluid administration without stroke volume measurement can be detrimental to patient outcomes. Early detection and prompt treatment of shock states is essential to combat deleterious effects on critically ill patients. In addition to measuring traditional hemodynamic variables, the use of advanced variables such as hypotension prediction index, dynamic arterial elastance, and systolic slope can improve the precision of treat ment for critically ill patients. Using predictive analytics can help the bedside critical care nurse provide patient care that is proactive rather than reactive.

Effects of social influence and implementation climate and leadership on nurse-led early mobility behaviours in critical care.

INTRODUCTION: Early mobility (EM), initiating and advancing physical activity in the earliest days of critical illness, has been described as the most difficult component of the ABCDEF bundle to implement and coordinate. Successful implementation of EM in clinical practice requires multiple targeted implementation strategies. OBJECTIVE: Describe the associations of nurses' EM attitudes, subjective norms, perceived behavioural control, intention, and implementation climate and leadership with self-reported and documented EM behaviour in the intensive care unit (ICU). DESIGN: This was a two-site, descriptive, cross-sectional study to explore nurses' perception of the factors influencing EM adherence. SETTING: Three ICUs (medical, surgical and cardiovascular) in an academic medical centre and two ICUs (medical/surgical and cardiovascular) in a regional medical centre in middle Tennessee. PATIENTS: Critically ill adults. INTERVENTIONS: None. MAIN OUTCOME MEASURES: A 34-item investigator-developed survey, Implementation Leadership Scale, and Implementation Climate Scale were administered to ICU nurses. Survey development was informed by a Theory of Planned Behavior based elicitation study and implementation science frameworks. RESULTS: The academic medical centre had markedly lower EM documentation. We found no difference in nurses' EM attitudinal beliefs, social influence, facilitators, and barriers at both sites. Nurses perceived moderate social influence to perform EM similarly across sites and considerable control over their ability to perform EM. We did note site differences for implementation climate and leadership and objective EM adherence with the regional community medical centre demonstrating statistically significant relationships of implementation climate and leadership with self-report and documented EM behaviours. CONCLUSIONS: We identified contextual differences in implementation climate and leadership influence when comparing nurse EM behaviours. Streamlined documentation, leadership advocacy for interprofessional coordination and manpower support, and multicomponent context-based implementation strategies could contribute to better EM adherence.

A multisite study of multidisciplinary ICU team member beliefs toward early mobility.

BACKGROUND: Early mobility is underutilized in critical care. OBJECTIVE: Describe multidisciplinary intensive care unit (ICU) providers beliefs about the conduct of early mobility during critical illness. METHODS: A 7-item elicitation survey was administered to a multidisciplinary sample of ICU team members. We conducted independent thematic analysis of n = 95 surveys. RESULTS: Analysis resulted in three themes: immediate risk vs. long-term reward conflict, nurse is the initiator and coordinator of early mobilization, and situational factors. Staffing was the primary facilitator and barrier to early mobility. Enablers included protection from complications of hospitalization, reduced hospital length of stay, and improved patient morale. Barriers strongly revolved around team member risk aversion (e.g., falls, hemodynamic instability, line dislodgment). Nurses were equally identified as positive and negative referents for early mobility. CONCLUSIONS: Strong positive and negative attitudinal beliefs were elicited. Early mobility is a protective behavior that requires sufficient numbers of trained staff and equipment.

The use and usefulness of ICU diaries to support family members of critically ill patients.

PURPOSE: To analyze and describe the use and usefulness of the ICU diary to support family members of critically ill patients. MATERIALS AND METHODS: A socio-technical systems model (SEIPS 2.0) guided data collection and analysis in this study aimed to gain a holistic understanding of factors that shape ICU diary processes and family requirements for support. Triangulated data sources, including interviews, observations, and photographs, were content analyzed for person, task, tool, and context attributes determining the use and usefulness of ICU diaries. Researchers recruited family members of critically ill patients admitted to ICUs in two hospitals (urban, rural) in the southeastern United States. RESULTS: Nineteen female (100%) family members participated in this study. ICU diaries were used and adapted by family members to cope with the ICU experience in multiple ways. Results indicate that staff support, easy access, embedded instructional format, early initiation, and family ownership facilitated ICU diary use by family members. The ICU diary was useful as a medium to process emotions and gain insights, reduce stress, track information, and communicate with the staff and the patient. CONCLUSIONS: The ICU diary is useful to family members as a stress reduction, information management, and communication tool. The design of ICU diary implementations must address system factors to assure family members receive benefits from diary use. Further research is needed to expand our understanding of the optimal structure, process, and content of ICU diary implementations.

The Effects of Social Influence on Nurses' Hand Hygiene Behaviors.

OBJECTIVE: The aim of this article is to describe the associations of nurses' hand hygiene (HH) attitudes, subjective norms, and perceived behavioral control with observed and self-reported HH behavior. BACKGROUND: Hand hygiene is an essential strategy to prevent healthcare-associated infections. Despite tremendous efforts, nurses' HH adherence rates remain suboptimal. METHODS: This quantitative descriptive study of ICU nurses in the southeastern United States was guided by the theory of planned behavior. The self-administered Patient Safety Opinion Survey and iScrub application, which facilitates observation, comprised the data set. RESULTS: Nurses' observed HH median was 55%; tendency to self-report was a much higher 90%. Subjective norm and perceived control scores were associated with observed and self-reported HH (P < .05) but not attitude scores or reports of intention. CONCLUSIONS: Nurses' subjective norm and perceived control are associated with observed and self-reported HH performance. Healthcare workers overestimate their HH performance. Findings suggest future research to explore manipulators of these variables to change nurses' HH behavior.

An elicitation study of critical care nurses' salient hand hygiene beliefs.

AIM: To describe critical care nurses' hand hygiene attitudinal, normative referent, and control beliefs. BACKGROUND: Hand hygiene is the primary strategy to prevent healthcare-associated infections. Social influence is an underdeveloped hand hygiene strategy. METHODS: This qualitative descriptive study was conducted with 25 ICU nurses in the southeastern United States. Data were collected using the Nurses' Salient Belief Instrument. RESULTS: Thematic analysis generated four themes: Hand Hygiene is Protective; Nurses look to Nurses; Time-related Concerns; and Convenience is Essential. CONCLUSION: Nurses look to nurses as hand hygiene referents and believe hand hygiene is a protective behaviour that requires time and functional equipment.

Obstacles to Shared Expectations in a Burn Intensive Care Unit.

Critical care patients are dependent on the health care team and their family members to effect care goals that are consistent with their core values and wishes. This study aimed to identify and understand how obstacles to communication affect these two disparate groups. Ten burn intensive care unit (BICU) care team and 20 family members participated in in-depth semistructured interviews. A two-cycle coding, inductive analytical approach was used to derive three obstacle metathemes: family engagement, information exchange, and process transparency and standardization. However, care team and family members' themes within each metatheme were different. Although the thematic structure was derived inductively, our findings in retrospect appeared to be consistent with Law's four resistances associated with actor-networks. From this perspective, actor-network theory provides a plausible explanation for perceived obstacles and may, in the future, guide the development of interventions to improve shared agency across networks.