The impact of nursing workforce skill-mix on patient outcomes in intensive care units in Victoria, Australia.

Objective: This article aims to examine the impact of nursing workforce skill-mix (percentage of critical care registered nurses [CCRN]) in the intensive care unit (ICU) during a patient's stay. Design: Registry linked cohort study of the Australian and New Zealand Intensive Care Society Adult Patient Database and the Critical Health Resources Information System using real-time nursing workforce data. Settings: Fifteen public and 5 private hospital ICUs in Victoria, Australia. Participants: There were 16,618 adult patients admitted between 1 December 2021 and 30 September 2022. Main outcome measures: Primary outcome: in-hospital mortality. Secondary outcomes: in-ICU mortality, development of delirium, pressure injury, duration of stay in-ICU and hospital, after-hours discharge from ICU and readmission to ICU. Results: In total, 6563 (39.5%) patients were cared for in ICUs with >75% CCRN, 7695 (46.3%) in ICUs with 50-75% CCRN, and 2360 (14.2%) in ICUs with <50% CCRN. In-hospital mortality was 534 (8.1%) vs. 859 (11.2%) vs. 252 (10.7%) respectively. After adjusting for confounders, patients cared for in ICUs with 50-75% CCRN (adjusted OR 1.21 [95% CI 1.02-1.45]) were more likely to die compared to patients in ICUs with >75% CCRN. A similar but non-significant trend was seen in ICUs with <50% CCRN (adjusted OR 1.21 [95% CI 0.94-1.55]), when compared to patients in ICUs with >75% CCRN. In-ICU mortality, delirium, pressure injuries, after-hours discharge and ICU length of stay were lower in ICUs with CCRN>75%. Conclusion: The nursing skill-mix in ICU impacts outcomes and should be routinely monitored. Health system regulators, hospital administrators and ICU leaders should ensure nursing workforce planning and education align with these findings to maximise patient outcomes.

An exploration of intensive care nurses' perceptions of workload in providing extracorporeal membrane oxygenation (ECMO) support: A descriptive qualitative study.

BACKGROUND: There is increasing use of extracorporeal membrane oxygenation (ECMO) in intensive care, where nurses provide the majority of the required ongoing care of cannulas, circuit, and console. Limited evidence currently exists that details nursing perspectives, experiences, and challenges with workload in the provision of ECMO care. OBJECTIVE: The objective of this study was to investigate intensive care nurses' perceptions of workload in providing specialist ECMO therapy and care in a high-volume ECMO centre. METHODS: The study used a qualitative descriptive methodology through semistructured interviews. Data were analysed using an inductive thematic analysis approach following Braun and Clarke's iterative process. This study was conducted in an intensive care unit within an Australian public, quaternary, university-affiliated hospital, which provides specialist state-wide service for ECMO. FINDINGS: Thirty ECMO-specialist trained intensive care nurses were interviewed. This study identified three key themes: (i) opportunity; (ii) knowledge and responsibilities; and (iii) systems and structures impacting on intensive care nurses' workload in providing ECMO supportive therapy. CONCLUSIONS: Intensive care nurses require advanced clinical and critical thinking skills. Intensive care nurses are motivated and engaged to learn and acquire ECMO skills and competency as part of their ongoing professional development. Providing bedside ECMO management requires constant monitoring and surveillance from nurses to care for the one of the most critically unwell patient populations in the intensive care unit setting. As such, ECMO nursing services require a suitably trained and educated workforce of intensive care trained nurses. ECMO services provide clinical development opportunities for nurses, increase their scope of practice, and create advanced practice-specialist roles.

Intensive care unit nurses' perceptions of debriefing after critical incidents: A qualitative descriptive study.

BACKGROUND: Intensive care unit (ICU) nurses are exposed to critical incidents daily at their workplace, which may have long-term physical and psychological impacts. Despite the growing evidence supporting clinical debriefing in health care to prevent these impacts, a scarcity of literature exists to support its use in the adult intensive care setting. OBJECTIVES: The objective of this study was to explore nurses' perceptions of clinical debriefing after critical incidents in an adult ICU. METHODS: A qualitative descriptive design was utilised. Thematic analysis of data from individual semistructured interviews with six ICU nurses was undertaken. FINDINGS: In this study, two themes were identified. Firstly, participants valued hot debriefing after critical incidents for the key reasons of having an opportunity to reflect on and learn from a critical incident and reduce normalisation of stressful situations. Secondly, when logistical factors such as communication, timing, and location were not considered, the attendance at debriefings was negatively influenced. Participants identified that ICU nurses commonly prioritised patient tasks over attending a debrief; therefore, teamwork and flexibility with logistics was crucial. CONCLUSIONS: Hot debriefing, of a short duration and close to the time of the event, was valued and played an important role in staff wellbeing and self-care, contributing to preventing self-blame and normalisation of stressful situations. A clearer definition of the term along with greater recognition of types of events that could be considered critical incidents is required for staff support after critical incidents in the complex intensive care setting.

Nursing workload and patient-focused outcomes in intensive care: A systematic review.

The aim of this systematic review was to examine the association of nursing workload on patient outcomes in intensive care units. The primary outcome measure was patient mortality, with adverse events (AE), the secondary outcome measures. Electronic search of databases including MEDLINE, CINAHL, Cochrane, EMCARE, Scopus, and Web of Science were performed. Studies were excluded if they were in non-ICU settings, pediatric, neonatal populations, or if the abstract/full text was unavailable. Risk of bias was assessed by the ROBINS-I tool. After screening 4129 articles, 32 studies were identified as meeting inclusion criteria. The majority of included studies were assessed as having a moderate risk of bias. The nursing activities score (NAS) was the most frequently used tool to assess nursing workload. Our systematic review identified that higher nursing workload was associated with patient-focused outcomes, including increased mortality and AE in the intensive care setting. The varied approaches of measuring and reporting nursing workload make it difficult to translate the findings of the impact of nursing workload on patient outcomes in intensive care settings.

The impact of nursing skill-mix on adverse events in intensive care: a single centre cohort study.

BACKGROUND: The highly complex and technological environment of critical care manages the most critically unwell patients in the hospital system, as such there is a need for a highly trained nursing workforce. Intensive care is considered a high-risk area for errors and adverse events (AE) due to the severity of illness and number of procedures performed. OBJECTIVE: To investigate if the percentage of Critical Care Registered Nurses (CCRN) within an Intensive Care Unit (ICU) is associated with an increased risk of patients experiencing an AE. DESIGN & SETTING: We conducted a retrospective cohort study of patients admitted between January 2016 and December 2020 to a tertiary ICU in Australia. Descriptive statistics and multivariable logistic regression were used to investigate the relationship between the proportion of CCRNs each month and the occurrence of an AE defined as any one of a medication error, fall, pressure injury or unplanned removal of a central venous catheter or endotracheal tube per patient. RESULTS: A total of 13,560 patients were included in the study, with 854 (6.3%) experiencing one AE. Patients with an AE were associated with higher illness severity and frailty scores. They were more commonly admitted after medical emergency team response calls and were less commonly elective ICU admissions. Those with an AE had longer ICU and in-hospital length of stay, and higher ICU and in-hospital mortality, on average. After adjusting for ICU LOS and acute severity of illness, being admitted during a month of higher critical care nursing skill-mix was associated with a statistically significant lower odds of having a subsequent AE (OR 0.966 [95% CI: 0.944-0.988], p 0.003). CONCLUSION: An increasing percentage of CCRNs is independently associated with a lower risk-adjusted likelihood of an AE. Increasing the skill-mix of the ICU nursing staff may reduce the occurrence of AEs and lead to improved patient outcomes.

The relationship between nursing skill mix and severity of illness of patients admitted in Australian and New Zealand intensive care units.

BACKGROUND: Critically ill patients in the intensive care environment require an appropriate nursing workforce to improve quality of care and patient outcomes. However, limited information exists as to the relationship between severity of illness and nursing skill mix in the intensive care. OBJECTIVE: The aim of this study was to describe the variation in nursing skill mix across different hospital types and to determine if this was associated with severity of illness of critically ill patients admitted to adult intensive care units (ICUs) in Australia and New Zealand. DESIGN & SETTING: A retrospective cohort study using the Australia and New Zealand Intensive Care Society Adult Patient Database (to provide information on patient demographics, severity of illness, and outcome) and the Critical Care Resources Registry (to provide information on annual nursing staffing levels and hospital type) from July 2014 to June 2020. Four hospital types (metropolitan, private, rural/regional, and tertiary) and three patient groups (elective surgical, emergency surgical, and medical) were examined. MAIN OUTCOME MEASURE: The main outcome measure was the proportion of critical care specialist registered nurses (RNs) expressed as a percentage of the full-time equivalent (FTE) of total RNs working within each ICU each year, as reported annually to the Critical Care Resources Registry. RESULTS: Data were examined for 184 ICUs in Australia and New Zealand. During the 6-year study period, 770 747 patients were admitted to these ICUs. Across Australia and New Zealand, the median percentage of registered nursing FTE with a critical care qualification for each ICU (n = 184) was 59.1% (interquartile range [IQR] = 48.9-71.6). The percentage FTE of critical care specialist RNs was highest in private [63.7% (IQR = 52.6-78.2)] and tertiary ICUs [58.1% (IQR = 51.2-70.2)], followed by metropolitan ICUs [56.0% (IQR = 44.5-68.9)] with the lowest in rural/regional hospitals [55.9% (IQR = 44.9-70.0)]. In ICUs with higher percentage FTE of critical care specialist RNs, patients had higher severity of illness, most notably in tertiary and private ICUs. This relationship was persistent across all hospital types when examining subgroups of emergency surgical and medical patients and in multivariable analysis after adjusting for the type of hospital and relative percentage of each diagnostic group. CONCLUSIONS: In Australian and New Zealand ICUs, the highest acuity patients are cared for by nursing teams with the highest percentage FTE of critical care specialist RNs. The Australian and New Zealand healthcare system has a critical care nursing workforce which scales to meet the acuity of ICU patients across Australia and New Zealand.

Nursing workforce, education, and training challenges to implementing extracorporeal membrane oxygenation services in Australian intensive care units: A qualitative substudy.

BACKGROUND: The use of extracorporeal membrane oxygenation (ECMO) is increasing in the management of critical care patients. ECMO service delivery requires an organisation-supported approach to ensure appropriate resources to deliver training, equipment, capacity, staffing, and the required model of care for quality care delivery. The aim of this nested substudy was to explore challenges specific to nursing staff in ECMO services in Australian intensive care units. METHODS: This was a nested substudy within a qualitative study using semistructured focus group discussions conducted with 83 health professionals, which included 40 nurses. There were 14 focus groups across 14 ECMO centres participating in the binational ECMO (EXCEL) registry of Australia and New Zealand. An inductive thematic analysis focused on the nurse's experiences of the barriers and facilitators for nursing in providing an ECMO service. RESULTS: Four themes emerged relating to the nurse's experience of implementing ECMO services: workforce requirements, workload demands, models of care, and level of experience. The complexity and intensity of caring for ECMO patients may need to be considered an additional factor in the burnout in critical care nurses. Current nursing ratios and responsibilities in critical care need to be considered, with the opportunity for the development of specialist advanced practitioner nursing roles. CONCLUSION: This study highlights the challenges for nursing in providing ECMO services in the intensive care setting. The complexity and intensity of ECMO is challenging and leads to concerns regarding burnout and workforce preparedness. New models of care need to be considered to mitigate the barriers for nursing identified across ECMO centres.

A Randomized Controlled Trial of the Prevent Alcohol and Risk-Related Trauma in Youth Program in Reducing Alcohol-Related Harms in Young Naval Trainees.

BACKGROUND: The aim of this study was to test whether participation in an alcohol risk reduction program known as Prevent Alcohol and Risk-Related Trauma in Youth (P.A.R.T.Y.) is effective in reducing the prevalence of risky drinking at 12 months' post-intervention in a sample of Royal Australian Navy (RAN) trainees. METHODS: A non-blinded randomized controlled trial of 952 RAN trainees comparing two forms of P.A.R.T.Y. plus RAN annual alcohol and other drug awareness training with annual alcohol and other drugs awareness training only (Control). Participants were screened at baseline and at 12-month follow-up using the Alcohol Use Disorders Identification Test (AUDIT). Participants were randomized to one of three arms: (1) in-hospital P.A.R.T.Y program, (2) on-base P.A.R.T.Y. program, or (3) control.The primary outcome measure was the percentage of participants reporting an AUDIT score of 8 or above at 12 months in each group. A secondary outcome considered was reports of alcohol-related incidents in the 12-month follow-up. RESULTS: There was no difference in the risk of reporting an AUDIT score of 8 or above in either the in-hospital (Relative Risk (RR) 0.96, 95% CI: 0.75-1.23; P = .75) or on-base (RR 1.11, 95% CI: 0.89-1.369; P = 0.35) intervention groups, compared to the control group. Compared to the on-base group, there was no difference in the risk of reporting an AUDIT score of 8 or above in the in-hospital group (RR 1.16, 95% CI: 0.90-1.48; P = .24). The rate of reporting an alcohol-related incident was not different for the in-hospital (Hazard Ratio (HR) 0.60, 95% CI: 0.27-1.33; P = .21) or on-base (HR 0.50, 95% CI: 0.21-1.16; P = .11) intervention groups when compared to the control group. CONCLUSION: Participation in either an on-base or an in-hospital P.A.R.T.Y. program did not affect the proportion of naval trainee participants screening positive for risky drinking on the AUDIT.

Nursing workforce deployment and intensive care unit strain during the COVID-19 pandemic in Victoria, Australia.

BACKGROUND: The COVID-19 pandemic demanded intensive care units (ICUs) globally to expand to meet increasing patient numbers requiring critical care. Critical care nurses were a finite resource in this challenge to meet growing patient numbers, necessitating redeployment of nursing staff to work in ICUs. OBJECTIVE: Our aim was to describe the extent and manner by which the increased demand for ICU care during the COVID-19 pandemic was met by ICU nursing workforce expansion in the late 2021 and early 2022 in Victoria, Australia. METHODS: This is a retrospective cohort study of Victorian ICUs who contributed nursing data to the Critical Health Information System from 1 December 2021 to 11 April 2022. Bedside nursing workforce data, in categories as defined by Safer Care Victoria's pandemic response guidelines, were analysed. The primary outcome was 'insufficient ICU skill mix'-whenever a site had more patients needing 1:1 critical care nursing care than the mean daily number of experienced critical care nursing staff. RESULTS: Overall, data from 24 of the 47 Victorian ICUs were eligible for analysis. Insufficient ICU skill mix occurred on 10.3% (280/2725) days at 66.7% (16/24) of ICUs, most commonly during the peak phase from December to mid-February. The insufficient ICU skill mix was more likely to occur when there were more additional ICU beds open over the 'business-as-usual' number. Counterfactual analysis suggested that had there been no redeployment of staff to the ICU, reduced nursing ratios, with inability to provide 1:1 care, would have occurred on 15.2% (415/2725) days at 91.7% (22/24) ICUs. CONCLUSION: The redeployment of nurses into the ICU was necessary. However, despite this, at times, some ICUs had insufficient staff to cope with the number and acuity of patients. Further research is needed to examine the impact of ICU nursing models of care on patient outcomes and on nurse outcomes.

The impact of the intensive care unit family liaison nurse role on communication during the COVID-19 pandemic: A qualitative descriptive study of healthcare professionals' perspectives.

BACKGROUND: The COVID-19 pandemic has deeply impacted patient and family communication and patient- and family-centred care in the intensive care unit (ICU). A new role-the ICU Family Liaison Nurse (FLN)-was introduced in an Australian metropolitan hospital ICU to facilitate communication between patient and family and ICU healthcare professionals, although there is limited knowledge about the impact of this from the ICU healthcare professionals' perspectives. OBJECTIVE: The aim of this study was to explore the impact of the ICU FLN role on communication with patients and their family during the COVID-19 pandemic, from the ICU healthcare professionals' perspectives. METHODS: A qualitative descriptive study was conducted. Seven participants including ICU FLNs, ICU doctors, nurses, and social workers who worked with the ICU FLNs were interviewed. Thematic analysis was used to analyse the data. RESULTS: Two main themes related to the ICU FLN role were identified. First, the COVID-19 pandemic posed challenges to patient and family communication, but it also created opportunities to improve patient and family communication. Second, the ICU FLN role brought beneficial impacts to the ICU healthcare professionals' workflow and work experience, as well as patient and family communication. The ICU FLN role has potential benefits that extend beyond the pandemic. CONCLUSION: We found that during the COVID-19 pandemic, the ICU FLN role was acceptable, beneficial, and appreciated from the ICU healthcare professionals' perspectives. Further research should continue the evaluation of the ICU FLN role during and post the pandemic.

Workplace intervention programmes for decreasing alcohol use in military personnel: a systematic review.

INTRODUCTION: Harmful or risky-single occasion drinking (RSOD) alcohol use in the military is a significant problem. However, most studies of interventions have focused on veterans, representing a missed opportunity for intervention with active military personnel. Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework, the aim of this systematic review was to analyse and synthesise the evidence related to workplace-based interventions for reducing alcohol use in active-duty military personnel. METHODS: Four electronic databases and reference lists of relevant articles were searched from database inception until 20 January 2020. This review focused on experimental and quasi-experimental studies of active-duty military personnel. Data extraction and methodological quality assessment were independently performed by two reviewers using a standardised checklist. A third reviewer was used to arbitrate the disputed studies for final selection. RESULTS: The search yielded seven studies from an initial 1582 records identified. A range of interventions were used in these studies (four randomised controlled trials, two non-randomised trials and one before and after cohort study), including web-based approaches, telephone-delivered interventions and individual and group-based face-to-face interventions. Seven studies found decreased drinking, measured using a range of outcomes, following the intervention. However, this was not sustained in the longer term in any of the studies. CONCLUSIONS: The low methodological rigour of most studies limited the capacity to demonstrate the efficacy of the interventions studied. Given the importance of reducing harmful or RSOD use of alcohol in the military, future studies would benefit from improved methodological rigour including ensuring adequate study power, randomisation, selection of validated outcome measures, including measures other than consumption (eg, attitudinal measures), and longer-term follow-up. There is also a need to develop methods that ensure participant loss to follow-up is minimised.

Comparing short versions of the Alcohol Use Disorders Identification Test (AUDIT) in a military cohort.

BACKGROUND: The Alcohol Use Disorders Identification Test (AUDIT) is widely used for monitoring harmful alcohol consumption among high-risk populations. A number of short versions of AUDIT have been developed for use in time-constrained settings. In military populations, a range of AUDIT variations have been used, but the optimal combination of AUDIT items has not been determined. METHODS: A total of 952 participants (80% male), recruited as part of a wider study, completed the AUDIT-10. We systematically assessed all possible combinations of three or four AUDIT items and established AUDIT variations using the following statistics: Cronbach's alpha (internal consistency), variance explained (R2) and Pearson's correlation coefficient (concurrent validity). RESULTS: Median AUDIT-10 score was 7 for males and 6 for females, and 380 (40%) participants were classified as having a score indicative of harmful or hazardous alcohol use (≥8) according to WHO classifications.A novel four-item AUDIT variation (3, 4, 8 and 9) performed consistently higher than established variations across statistical measures; it explained 85% of variance in AUDIT-10, had a Pearson's correlation of 0.92 and Cronbach's alpha was 0.63. The FAST, an established shortened AUDIT variant, together with several other four-item novel variants of AUDIT-10 performed similarly. The AUDIT-C performed consistently low on all measures, but with a satisfactory level of internal consistency (75%). CONCLUSION: Shortened AUDIT variations may be suitable alternatives to the full AUDIT for screening hazardous alcohol consumption in military populations. Four-item AUDIT variations focused on short-term risky drinking and its consequences performed better than three item versions. TRIAL REGISTRATION NUMBER: ACTRN12614001332617.

Measuring the effectiveness of in-hospital and on-base Prevent Alcohol and Risk-related Trauma in Youth (P.A.R.T.Y.) programs on reducing alcohol related harms in naval trainees: P.A.R.T.Y. Defence study protocol.

BACKGROUND: Reducing alcohol related harms in Australian Defence Force (ADF) trainees has been identified as a priority, but there are few evidence-based prevention programs available for the military setting. The study aims to test whether the P.A.R.T.Y. program delivered in-hospital or on-base, can reduce harmful alcohol consumption among ADF trainees. METHODS/DESIGN: The study is a 3-arm randomized controlled trial, involving 953 Royal Australian Navy trainees from a single base. Trainees, aged 18 to 30 years, will be randomly assigned to the study arms: i. in-hospital P.A.R.T.Y.; ii. On-base P.A.R.T.Y.; and iii. CONTROL GROUP: All groups will receive the routine ADF annual alcohol awareness training. The primary outcome is the proportion of participants reporting an Alcohol Use Disorders Identification Test (AUDIT) score of 8 or above at 12 months' post-intervention. The secondary outcome is the number of alcohol related incidents reported to the Royal Australian Navy (RAN) in the 12 months' post-intervention. DISCUSSION: This is the first trial of the use of the P.A.R.T.Y. program in the military. If the proposed intervention proves efficacious, it may be a useful program in the early education of RAN trainees. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12614001332617 , date of registration: 18/12/2014 'retrospectively registered'.

Variability of intravenous medication preparation in Australian and New Zealand intensive care units.

RATIONALE, AIM AND OBJECTIVE: In Australia and New Zealand, there are no established standards for the final presentations of prepared intravenous medications in Intensive Care Units (ICUs). Variability has the potential to contribute to deficiencies in safety, efficiency and cost effectiveness. This study aimed to examine the variability in the preparation of intravenous medications in ICUs. METHODS: An electronic survey was distributed to critical care pharmacists in Australia and New Zealand via an established email group. The preparation of vasopressors, inotropes, sedation, analgesia, heparin, insulin and neuromuscular blockers were examined. Respondents were asked about initial presentation, final concentration prepared, who prepared and current safety practices used. Questions also addressed opinions and attitudes to safety practices and responsibility for leading change. RESULTS: Forty responses to the survey were received, representing 17% of ICUs in Australia and New Zealand. Significant variation in final concentration was observed for all infusions except insulin and esmolol. The final volumes varied significantly for all drugs. The majority of infusions were prepared by nursing staff with only a small number of pre-prepared presentations currently in use. Labelling was usually hand-written with some colour-coding. Most respondents identified safety and efficiency but not cost effectiveness as likely to be improved by the use of pre-prepared infusions. Most respondents felt 'government' or peak clinical bodies should lead practice standardization. CONCLUSION: Significant variation exists in the preparation of intravenous medications across ICUs in Australia and New Zealand. Nationally or regionally coordinated rationalization and standardization could improve safety and efficiency and potentially reduce the barrier of cost.