Evaluation of a blended training solution for critical care nurses' work environment: Lessons learned from focus groups in four European countries.

AIM: The aim of this study was to evaluate a blended pilot training course on Healthy Work Environments (HWEs) for critical care nurses as follows: 1) to explore the experience of trainees and trainers who took part in the training; and 2) to identify the strengths and weaknesses of the training program in its potential transferability to nursing practice in Intensive Care Units (ICUs). BACKGROUND: Despite the evidence supporting the association between HWEs and job satisfaction, nursing retention, and patient outcomes, nurses still have high rates of burnout, mental health problems and intent to leave. To address this challenge, a blended training was created and piloted with the aim to highlight the relevance and impact of HWEs, enhancing its transferability to daily practice. The training was based on the six standards of HWEs as proposed by the American Association of Critical Care Nurses and created within an Erasmus + project. The pilot was delivered by trainers (critical care nursing educators) to critical care nurses and included six workshops of eight hours each (48 h in total) in each country. DESIGN: After the pilot testing, a qualitative approach, with focus group discussions was used. METHODS: All the trainees (n=82), who had attended at least one workshop were invited to participate in the focus groups. Overall, eight focus groups were held with critical care nurses who participated as trainees (n=39) from four testing countries: Cyprus, Croatia, Spain and Poland. One international focus group was held with trainers who conducted the training (n=4). Four more trainers completed the questionnaire online. All focus group were video recorded, and transcribed verbatim. Then, the national transcripts were translated into English. An inductive thematic analysis was carried out. FINDINGS: Three themes were identified: 1) Valuing the relevance of the training program and a positive learning experience; 2) A powerful insight leading to increased awareness and empowerment in personal and professional life; 3) Challenges identified in terms of training, follow up and management of change. Both trainees and trainers expressed a positive opinion with regard to the content of the training and the didactic methods used. They emphasized the strong influence of the training on their understanding of a HWEs, its impact in an ICU context and the need for action, mainly related to communication issues. CONCLUSION: The proposed blended training program may be used by trainers, who can enable nurses develop the competencies required to influence their work environment, in a context of shared responsibility.

The effectiveness of systematic pain assessment on critically ill patient outcomes: A randomised controlled trial.

BACKGROUND: Evidence suggests that critically ill patients' pain may still be underestimated. Systematic approaches to pain assessment are of paramount importance for improving patients' outcomes. OBJECTIVES: To investigate the effectiveness of a systematic approach to pain assessment on the incidence and intensity of pain and related clinical outcomes in critically ill patients. METHODS: Randomized controlled study with consecutive critically ill patients allocated to either a standard care only or a systematic pain assessment group. The Behavioral Pain Scale (BPS) and the Critical Pain Observation Tool (C-POT) were completed twice daily for all participants. In the intervention group, clinicians were notified of pain scores. Linear Mixed Models (LMM) for the longitudinal effect of the intervention were employed. RESULTS: A total of 117 patients were included (control: n=61; intervention: n2=56). The incidence of pain (C-POT >2) in the intervention group was significantly lower compared to the control group (p < .001). The intervention had a statistically significant effect on pain intensity (BPS, p = 0.01). The average total morphine equivalent dose in the intervention group was higher than in the control group (p = 0.045), as well as the average total dose of propofol (p = 0.027). There were no statistically significant differences in ICU mortality (23.4% vs 19.3%, p=0.38, odds ratio 0.82 [0.337-1.997]) and length of ICU stay (13.5, SD 11.1 vs 13.9, SD 9.5 days, p= 0.47). CONCLUSION: Systematic pain assessment may be associated with a decrease in the intensity and incidence of pain and influence the pharmacological management of pain and sedation of critically ill patients.

The use of serum extracellular vesicles for novel small molecule inhibitor cell delivery.

In Research Genetic Cancer Center (RGCC), we are in the process of synthesizing a novel ERK inhibitor. We have currently synthesized an intermediate molecule, RGCC169, that needed to be tested to confirm we are using the appropriate synthetic pathways. Because of the limited solubility the compound exhibits, a strategy had to be devised for the free entrance of the molecule into the cell. Extracellular vesicles (EVs) were isolated by polyethylene glycol precipitation and identified by western blot and scanning electron microscopy. Loading was determined by high-performance liquid chromatography, differential scanning calorimetry, and scanning electron microscopy. EV uptake was determined by fluorescent microscopy. The effect of EV-encapsulated RGCC169 was determined by MTT viability assay on MCF7 cells. RGCC169 was incorporated into EVs as shown by high-performance liquid chromatography (26.6%) and scanning electron microscopy. Differential scanning calorimetry peaks shifted from 100.84 to 108.79°C upon encapsulation. EVs were taken up by cells as evident from CD63 fluorescent signal inside the cell's cytoplasm. RGCC169 decreased MCF proliferation (93.5±2.2, P=0.02). EV-encapsulated RGCC169 decreased cell proliferation even further (93.5±2.2 vs. 81.6±2.8, P=0.0002). RGCC169 was successfully loaded into serum EVs possibly by incorporation into the lipid membrane. EVs were taken up by MCF7 cells possibly by endocytic pathways. Although RGCC169 significantly reduced MCF7 viability at 3 µmol/l, the same concentration of RGCC169 encapsulated into EVs decreased cells viability even further. Our findings validate the correctness of our methods and are very promising for the achievement of our final goal, that is, the synthesis of a novel cytotoxic agent.

Clinical practices to promote sleep in the ICU: A multinational survey.

PURPOSE: To describe sleep assessment and strategies to promote sleep in adult ICUs in ten countries. METHODS: Multicenter, self-administered survey sent to nurse managers. RESULTS: Response rate was 66% with 522 ICUs providing data. 'Lying quietly with closed eyes' was the characteristic most frequently perceived as indicative of sleep by >60% of responding ICUs in all countries except Italy. Few ICUs (9%) had a protocol for sleep management or used sleep questionnaires (1%). Compared to ICUs in Northern Europe, those in central Europe were more likely to have a sleep promoting protocol (p < 0.001), and to want to implement a protocol (p < 0.001). In >80% of responding ICUs, the most common non-pharmacological sleep-promoting interventions were reducing ICU staff noise, light, and nurse interventions at night; only 18% used earplugs frequently. Approximately 50% of ICUs reported sleep medication selection and assessment of effect were performed by physicians and nurses collaboratively. A multivariable model identified perceived nursing influence on sleep decision-making was associated with asking patients or family about sleep preferences (p = 0.004). CONCLUSIONS: We found variation in sleep promotion interventions across European regions with few ICUs using sleep assessment questionnaires or sleep promoting protocols. However, many ICUs perceive implementation of sleep protocols important, particularly those in central Europe.

Nurse-physician collaboration and associations with perceived autonomy in Cypriot critical care nurses.

BACKGROUND AND AIMS: Increased nurse-physician collaboration is a factor in improved patient outcomes. Limited autonomy of nurses has been proposed as a barrier to collaboration. This study aims to explore nurse-physician collaboration and potential associations with nurses' autonomy and pertinent nurses' characteristics in adult intensive care units (ICUs) in Cyprus. DESIGN AND METHODS: Descriptive correlational study with sampling of the entire adult ICU nurses' population in Cyprus (five ICUs in four public hospitals, n = 163, response rate 88·58%). Nurse-physician collaboration was assessed by the Collaboration and Satisfaction About Care Decisions Scale (CSACD), and autonomy by the Varjus et al. scale. RESULTS: The average CSACD score was 36·36 ± 13·30 (range: 7-70), implying low levels of collaboration and satisfaction with care decisions. Male participants reported significantly lower CSACD scores (t = 2·056, p = 0·04). CSACD correlated positively with years of ICU nursing experience (r = 0·332, p < 0·0001) and professional satisfaction (r = 0·455, p < 0·0001). The mean autonomy score was 76·15 ± 16·84 (range: 18-108). Higher degree of perceived collaboration (CSACD scores) associated with higher autonomy scores (r = 0·508, p <0·0001). CONCLUSIONS: Our findings imply low levels of nurse-physician collaboration and satisfaction with care decisions and moderate levels of autonomy in ICU nurses in Cyprus. RELEVANCE TO CLINICAL PRACTICE: The results provide insight into the association between nurse-physician collaboration and nurses' autonomy and the correlating factors.

The Impact of Pain Assessment on Critically Ill Patients' Outcomes: A Systematic Review.

In critically ill patients, pain is a major problem. Efficient pain management depends on a systematic, comprehensive assessment of pain. We aimed to review and synthesize current evidence on the impact of a systematic approach to pain assessment on critically ill patients' outcomes. A systematic review of published studies (CINAHL, PUBMED, SCOPUS, EMBASE, and COCHRANE databases) with predetermined eligibility criteria was undertaken. Methodological quality was assessed by the EPHPP quality assessment tool. A total of 10 eligible studies were identified. Due to big heterogeneity, quantitative synthesis was not feasible. Most studies indicated the frequency, duration of pain assessment, and types of pain assessment tools. Methodological quality assessment yielded "strong" ratings for 5/10 and "weak" ratings for 3/10 studies. Implementation of systematic approaches to pain assessment appears to associate with more frequent documented reports of pain and more efficient decisions for pain management. There was evidence of favorable effects on pain intensity, duration of mechanical ventilation, length of ICU stay, mortality, adverse events, and complications. This systematic review demonstrates a link between systematic pain assessment and outcome in critical illness. However, the current level of evidence is insufficient to draw firm conclusions. More high quality randomized clinical studies are needed.

Development of an instrument to determine competencies of postgraduate ICU nurses in Cyprus.

AIMS AND OBJECTIVES: The study sought to explore the expected competencies for postgraduate intensive care unit nurses aiming to develop a future competency-based curriculum. The aim of this part of the study is to develop a new instrument to determine what competencies are expected of postgraduate critical care nurses. BACKGROUND: Despite existing competency frameworks that emerged from research in the area of critical care, globally and within countries there is diversity and an ongoing debate regarding level of critical care education, outcomes and competencies acquired. DESIGN AND METHODS: A combination of qualitative and quantitative approach was used. In first stage (qualitative), focus groups and interviews were used aiming to explore critical care nurses views concerning expected competencies of postgraduate critical care nurses. In second stage (quantitative), an 81 items Likert scale questionnaire, which was designed based on qualitative data and literature, was distributed among critical care nurses in Cyprus (n: 234, response rate 66%) aiming to receive feedback from clinical nurses and validate the instrument. Psychometric approaches such as internal consistency reliability using Cronbach's α and construct validity were used to validate the instrument. RESULTS: The final questionnaire includes 72 items and has a four-dimensional structure. The four dimensions are (1) leadership/management and professional development, (2) decision-making and management of emergencies, (3) provision of care and professional practice and (4) ethical practice. All factors were highly reliable, with Cronbach's α ranging from 0·895 to 0·974. CONCLUSIONS: A new instrument to determine what competencies are expected of postgraduate critical care nurses was generated from this study. A new framework of competencies is grounded on this study that addresses the holistic, individualized and ethically informed quality care of critically ill and may inform educational strategies. RELEVANCE TO CLINICAL PRACTICE: Critical care nurses competencies need to be determined for quality care and speciality development.

Nicosia General Hospital cardiac arrest team: first year's practice and outcomes of in-hospital resuscitation.

INTRODUCTION: In 2007, Nicosia General Hospital implemented a resuscitation policy. 378 nurses and 120 doctors were successfully trained in advanced life support (ALS) in order to staff cardiac arrest teams. The aim of this study was to assess the frequency of cardiac arrest and resuscitation outcomes in Nicosia General Hospital and assess any associations between the survival rate and the patient's characteristics. We also aimed to evaluate the effectiveness of in-hospital resuscitation in order to detect ways of improvement. METHODS: We prospectively analyzed the data on all cardiac arrest calls in Nicosia General Hospital between January and December 2007. Data were collected using the Utstein style. RESULTS: The cardiac arrest team (CAT) was called 83 times, of which 10 were false alarms. Cardiac arrest was identified in 69 calls, while 4 calls were respiratory arrests. The patients' mean age was 70.8 years (95% CI: 66.6-75.1). In 86% the initial rhythm was asystole/pulseless electrical activity (PEA) and in 14% ventricular fibrillation/tachycardia (VF/VT). Return of spontaneous circulation was achieved in 52% of the cases. Survival to discharge was achieved in 17.8% of the patients with arrest and in 14.5% of cardiac arrests. Patients with an initial rhythm of asystole/PEA were discharged in 5% and patients with VF/VT in 70% of cases. About 36% of the patients less than 60 years old and 12% of the patients older than 60 were discharged. The CAT arrived within 1.6 minutes, first shock in VF/VT was delivered within 1.5 minutes and the first adrenaline dose in asystole/PEA was given within 2.7 minutes. CONCLUSIONS: It is more likely for our patients to survive to discharge if they are less than 60 years old, they are hospitalized in the cardiology department and the initial rhythm is VF/VT. Our outcomes are similar to survival rates in larger studies. However, points of improvement have been identified and interventions need to be made in order to improve documentation and outcomes of in-hospital arrests.