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 organisation of nurse staffing in intensive care units: A qualitative study.

AIMS: To examine the organisation of the nursing workforce in intensive care units and identify factors that influence how the workforce operates. BACKGROUND: Pre-pandemic UK survey data show that up to 60% of intensive care units did not meet locally agreed staffing numbers and 40% of ICUs were closing beds at least once a week because of workforce shortages, specifically nursing. Nurse staffing in intensive care is based on the assumption that sicker patients need more nursing resource than those recovering from critical illness. These standards are based on historical working, and expert professional consensus, deemed the weakest form of evidence. METHODS: Focus groups with intensive care health care professionals (n = 52 participants) and individual interviews with critical care network leads and policy leads (n = 14 participants) in England between December 2019 and July 2020. Data were analysed using framework analysis. FINDINGS: Three themes were identified: the constraining or enabling nature of intensive care and hospital structures; whole team processes to mitigate nurse staffing shortfalls; and the impact of nurse staffing on patient, staff and intensive care flow outcomes. Staff made decisions about staffing throughout a shift and were influenced by a combination of factors illuminated in the three themes. CONCLUSIONS: Whilst nurse:patient ratios were clearly used to set the nursing establishment, it was clear that rostering and allocation/re-allocation during a shift took into account many other factors, such as patient and family nursing needs, staff well-being, intensive care layout and the experience, and availability, of other members of the multi-professional team. This has important implications for future planning for intensive care nurse staffing and highlights important factors to be accounted for in future research studies. IMPLICATIONS FOR NURSING MANAGEMENT: In order to safeguard patient and staff safety, factors such as the ICU layout need to be considered in staffing decisions and the local business case for nurse staffing needs to reflect these factors. Patient safety in intensive care may not be best served by a blanket 'ratio' approach to nurse staffing, intended to apply uniformly across health services.

Nurse perspectives in the emergency department: The synergy tool in workload management and work engagement.

AIM: To explore emergency nurses' perceptions of how a nurse-driven patient needs assessment tool, the synergy tool, influenced their workload management. BACKGROUND: Quadruple Aim, particularly the fourth aim of improved staff work experiences, served as the conceptual framework to engage nurses in a participatory action research project. This project took place between 2017 and 2020 in two tertiary care emergency departments in one large Canadian city. METHOD: This study employed a qualitative descriptive component, focus group interviews and nurse comments on two open-ended survey questions. RESULTS: Use of the synergy tool heightened nurses' awareness of patients' holistic care needs. Nurses also stated how patient needs assessment data helped them identify unsafe workloads. CONCLUSIONS: The synergy tool, adapted for emergency department use by nurses, was a means to engage and empower nurses. Patient needs assessment data from the tool identified staffing gaps, resulting in additional nursing staff for both emergency departments. IMPLICATIONS FOR NURSING MANAGEMENT: A focus on patient needs assessment can be an effective way to address nurses' workload concerns.

Training load, recovery and game performance in semiprofessional male basketball: influence of individual characteristics and contextual factors.

This study examined the effects of individual characteristics and contextual factors on training load, pre-game recovery and game performance in adult male semi-professional basketball. Fourteen players were monitored, across a whole competitive season, with the session-RPE method to calculate weekly training load, and the Total Quality Recovery Scale to obtain pre-game recovery scores. Additionally, game-related statistics were gathered during official games to calculate the Performance Index Rating (PIR). Individual characteristics and contextual factors were grouped using k-means cluster analyses. Separate mixed linear models for repeated measures were performed to evaluate the single and combined (interaction) effects of individual characteristics (playing experience; playing position; playing time) and contextual factors (season phase; recovery cycle; previous game outcome; previous and upcoming opponent level) on weekly training load, pre-game recovery and PIR. Weekly load was higher in guards and medium minute-per-game (MPG) players, and lower for medium-experienced players, before facing high-level opponents, during later season phases and short recovery cycles (all p < 0.05). Pre-game recovery was lower in centers and high-experience players (p < 0.05). Game performance was better in high-MPG players (p < 0.05) and when facing low and medium-level opponents (p < 0.001). Interestingly, players performed better in games when the previous week's training load was low (p = 0.042). This study suggests that several individual characteristics and contextual factors need to be considered when monitoring training load (playing experience, playing position, playing time, recovery cycle, upcoming opponent level), recovery (playing experience, playing position) and game performance (opponent level, weekly training load, pre-game recovery) in basketball players during the competitive season.

Implementation of a model of emergency care in an Australian hospital.

AIM: Emergency departments are characterised by a fast-paced, quick turnover and high acuity workload, therefore appropriate staffing is vital to ensure positive patient outcomes. Models of care are frameworks in which safe and effective patient-to-nurse ratios can be ensured. The aim of this study was to implement a supportive and transparent model of emergency nursing care that provides structure - regardless of nursing staff profile, business or other demands; improvement to nursing workloads; and promotes individual responsibility and accountability for patient care. METHOD: A convergent parallel mixed-method approach was used. Quantitative data were analysed using descriptive statistics and the qualitative data used a thematic analysis to identify recurrent themes. RESULTS: Data post-implementation of the model of emergency nursing care indicate improved staff satisfaction in relation to workload, patient care and support structures. CONCLUSION: The development and implementation of a model of care in an emergency department improved staff workload and staff's perception of their ability to provide care.

A state wide validation and utilisation study of the Queensland emergency nursing workforce tool.

AIM: To describe and compare standard practice with a revised, assisted method for calculating emergency department nursing workforce requirements (using the emergency nursing workforce tool, ENWT) within 27 Queensland public hospital emergency departments (ED). BACKGROUND: Despite the presence of several methodologies used for staffing calculations, there is a necessity to refine measures of emergency department complexity and workload to determine appropriate staffing in order to meet patient safety needs and health service key priority indicators. METHODS: A descriptive comparative study design was employed. Of the 27 ED nurse unit managers (NUM) invited, 18 (67%) participated. RESULTS: No significant difference was noted in the full time equivalent (FTE) nursing requirement when standard vs. new (ENWT) methods were compared. The ENWT was more efficient (i.e. timely) and had better predictability than existing methods for calculating FTE nursing requirement. CONCLUSION: The methodology underpinning the ENWT may be useful to apply or adapt to settings other than the ED (e.g. intensive care, operating room) and disciplines within the ED other than nursing (e.g. medicine, allied health, porterage) to inform staffing requirements. IMPLICATIONS FOR NURSING MANAGEMENT: Findings from this research can be used to inform ED managers and health service planners regarding a standardized approach to calculating emergency nursing workforce needs.

An Interval Throwing Program for Baseball Pitchers Based upon Workload Data.

Background: Interval throwing programs (ITP) have been used for decades to enable baseball pitchers to return to competition after injury or surgery by gradually applying load to the throwing arm. Past programs have been based on personal experience; however, advances in our understanding of the biomechanics and workloads of throwing allow for a more modern data-based program to be developed. Hypothesis/Purpose: To 1) develop a updated ITP for rehabilitation of modern baseball pitchers based upon biomechanical and throwing workload data, and 2) compare the updated program with a past program to determine differences in chronic workload and acute:chronic workload ratios (ACWR). Study Design: Cross-sectional study. Methods: Workloads (i.e. daily, acute, chronic, and ACWR) for the original ITP were built from the prescribed throwing schedule. Elbow varus torque per throw was calculated based upon a relationship between elbow varus torque and throwing distance. Throw counts, daily/chronic/acute workloads, and ACWR were calculated and plotted over time. A new ITP was built to model current pitcher's throwing schedules and gradually increased ACWR over time. Results: The original ITP had a throwing schedule of 136 days, final chronic workload 15.0, and the ACWR above or below the "safe" range (i.e. 0.7 - 1.3) for 18% of the program with a peak of 1.61. The updated ITP was built to consist of a 217-day schedule, final chronic workload of 10.8, and deviated from the safe range for 9% of the program, with a peak of 1.33. Conclusion: The newly created ITP is more familiar to modern baseball pitchers while exhibiting a more gradual buildup of chronic workload than traditional ITP programs. This ITP may be used to return baseball pitchers back to competition as safely and efficiently as possible, and potentially with less risk of setbacks or reinjury. The ITP may be used following common injuries or surgeries to the throwing shoulder and elbow, such as Tommy John surgery, while also serving as a basis for future development of shorter duration ITPs. Level of Evidence: 2c.

Chronic Workload, Subjective Arm Health, and Throwing Injury in High School Baseball Players: 3-Year Retrospective Pilot Study.

BACKGROUND: Baseball workloads are monitored by pitch counts, appearances, innings per appearance, ball velocity, and distance, whereas current workload standards neglect throws made during nongame situations. The association between total workloads, subjective measures, and injury in baseball is poorly understood. The question remains whether baseball athletes are at higher risk of injury by throwing more often or if they generate injury resilience when appropriately transitioned into the higher demands of throwing. HYPOTHESIS: Increased chronic load, along with subjective arm health measures, are related to decreased injury risk. STUDY DESIGN: Clinical research. LEVEL OF EVIDENCE: Level 3. METHODS: A total of 49 male baseball players (age 17.9 ± 0.4 years, height 181.8 ± 6.8 cm, body mass 80.6 ± 9.1 kg) competing at the varsity high school level were included in this 3-year retrospective data analysis from 2016 to 2019. Players wore the motusTHROW sleeve and sensor during all throwing activities. RESULTS: A total of 898,492 throws and 9455 athletic exposures were captured with the motusTHROW sensors. There were 24 injuries recorded throughout the 3-year analysis, with 11 throwing-related and 13 non-throwing related injuries. Results of the 1-way analysis of variance found chronic load was significantly related to throwing-injury occurrence (P < 0.01). Six of the throwing-related injuries occurred when athletes had a chronic load greater than 11.3, marking 75th percentile across all observations. There was a relationship between arm health and throwing arm-related injury occurrence (P < 0.01). Higher chronic load was associated with increased throwing-related injuries even when adjusted for arm health (P = 0.01). Specifically, injuries were more likely to occur in pitchers (either as a combination player or pitcher only) with a chronic load greater than 9.2. CONCLUSION: This study revealed a significant relationship between chronic load, subjective arm health, and throwing-related injury in varsity high school baseball players. Contrary to our hypothesis, increased chronic load was associated with increased injury risk. However, subjective arm health measures remain a relevant factor in assessing injury risk. Normative data for this population also provide key information around positional demands along with overall demands of the sport during the competitive season and off-season.

Implementation of the Synergy Tool: A Potential Intervention to Relieve Health Care Worker Burnout.

(1) Background: Healthcare workers experienced rising burnout rates during and after the COVID-19 pandemic. A practice-academic collaboration between health services researchers and the surgical services program of a Canadian tertiary-care urban hospital was used to develop, implement and evaluate a potential burnout intervention, the Synergy tool. (2) Methods: Using participatory action research methods, this project involved four key phases: (I) an environmental scan and a baseline survey assessment, (II), a workshop, (III) Synergy tool implementation and (IV) a staffing plan workshop. A follow-up survey to evaluate the impact of Synergy tool use on healthcare worker burnout will be completed in 2023. (3) Results: A baseline survey assessment indicated high to severe levels of personal and work-related burnout prior to project initiation. During the project phases, there was high staff engagement with Synergy tool use to create patient care needs profiles and staffing recommendations. (4) Conclusions: As in previous research with the Synergy tool, this patient needs assessment approach is an efficient and effective way to engage direct care providers in identifying and scoring acuity and dependency needs for their specific patient populations. The Synergy tool approach to assessing patient needs holds promise as a means to engage direct care providers and to give them greater control over their practice-potentially serving as a buffer against burnout.

The usefulness of an ambulatory care pharmacy performance dashboard during the COVID-19 pandemic in a complex tertiary care system.

PURPOSE: To describe the usefulness of an innovative "semi-real-time" pharmacy dashboard in managing workload during the unpredictable coronavirus disease 2019 (COVID-19) pandemic. SUMMARY: We created a pharmacy dashboard to monitor workload and key performance indicators during the dynamic COVID-19 crisis. The dashboard accessed the prescribing workload from our clinical information system and filled prescriptions from robotic prescription dispensing systems. The aggregated data was visualized using modern tools. The dashboard presents performance data in near real time and is updated every 15 minutes. After validation during the early weeks of the COVID-19 crisis, the dashboard provided reliable data and served as a great decision support aid in calculating the backlog of prescribed but unfilled prescriptions. It also aided in adjusting manpower, identifying prescribing and dispensing patterns, identifying trends, and diverting staff resources to appropriate locations. The dashboard has been useful in clearing the backlog in a timely manner, staff planning, and predicting the next coming surge so that we can proactively minimize accumulation of backlogged prescriptions. CONCLUSION: Developing a dynamic, semi-real-time pharmacy dashboard during unstable circumstances such as those that have arisen during the COVID-19 pandemic can be very useful in ambulatory care pharmacy workload management.

Association of the acute:chronic workload ratio and wellness scores in premier league male hockey players.

Background: The relationship between acute:chronic workload ratios (ACWR) and the incidence of injury, as well as the relationship between subjective wellness scores and training load, is unclear in hockey players. Objectives: This study investigated these relationships to determine if the ACWR is a useful workload management tool for field hockey players. In addition, the study investigated the association between specific subjective wellness scores (fatigue, sleep quality, general muscle soreness, mood and stress level) and the acute:chronic workload ratio and training load. The study also assessed the association between individual players' training loads with the self-reported wellness scores. Methods: Fourteen male field hockey players from the men's first team at the University of the Witwatersrand participated in the study over ten weeks during a premier league competition phase. A Google form was completed within thirty minutes of every training session/match. This form consisted of questions that allowed for the calculation of the ACWR. Results: No incidence of injury was reported during the ten-week period. ACWR scores ranged between 0.67 and 1.87. The ACWR was associated with general muscle soreness (p = 0.010) and training load was associated with fatigue (p = 0.002), sleep quality (p = 0.05), general muscle soreness (p = 0.004), and mood (p=0.025). Conclusion: There may be some merit in the use of subjective wellness measures as workload management tools in field hockey. Further research is required to determine if there is an optimal ACWR for this sport.

Balancing workload of nurses: Linear mixed effects modelling to estimate required nursing time on surgical wards.

Aim: Quantifying the relation between patient characteristics and care time and explaining differences in nursing time between wards. Design: Academic hospital in the Netherlands. Six surgical wards, capacity 15-30 beds, 2012-2014. Methods: Linear mixed effects model to study the relation between patient characteristics and care time. Estimated marginal means to estimate baseline care time and differences between wards. Results: Nine patient characteristics significantly related to care time. Most required between 18 and 35 min extra, except "two or more IV/drip/drain" (8) and "one-on-one care" (156). Care time for minimum patient profile: 44-57 min and for average patient profile: 75-88 min. Sources of variation: nurse proficiency, patients, day-to-day variation within patients. The set of characteristics is short, simple and useful for planning and comparing workload. Explained variance up to 36%. Calculating estimated means per ward has not been done before. Nurse proficiency is an important factor.

An interview analysis of coordination behaviours in Out-of-Hours secondary care.

This paper seeks to elicit and structure the factors that shape the execution and, in particular, the coordination of work in Out of Hours care. Evenings and weekends in UK hospitals are managed by specific Out of Hours (OoH) care arrangements, and associated technology. Managing care within the constraints of staff availability and demands is a key concern for both patient care and staff wellbeing, yet has received little attention from healthcare human factors. A study of sixteen clinical staff used Critical Decision Method to understand how work is coordinated and the constraints and criteria that are applied by the roles managing OoH care. The analysis identified ten types of coordination decision that, in turn, underpinned three types of adaptive behaviour - pre-emption, information augmentation and self-organisation - that were crucial for the effective performance in OoH care. These behaviours explain how OoH staff manage the task demands placed on them, individually and as a team.

Relationship between workload and throwing injury in varsity baseball players.

OBJECTIVES: In this study we describe the first analysis of the relationship between acute-to-chronic valgus workload ratio (ACVR) and injury in baseball. DESIGN: Observational study. SETTING: Competitive, team sport. PARTICIPANTS: Eighteen, elite male baseball players (aged 17.0 ±â€¯0.7 year, height 185 ±â€¯5.7 cm, and mass 85.2 ±â€¯7.6 kg) competing at the varsity level participated in this six-month study. Each player wore the motusTHROW™ sleeve and sensor during pre-season training and the entire 2017 regular season. MAIN OUTCOME MEASURES: ACVR and injury. RESULTS: Overall there were a total of ten injuries recorded throughout the 2017 season amongst those wearing the sleeves, including six throwing-related injuries. Over 159 days of throwing, a total of 171,703 throws, and 1307 exposures were captured with the motusTHROW™ sensors. Five of the six throwing-related injuries occurred when athletes had an ACVR greater than 1.27, which marks the 75th percentile across all observations. Results from logistic regression suggested that ACVR was significantly related to injury occurrence (p < .05). This resulted in an odds ratio of 15.2 and a risk ratio of 14.9, meaning that ACVR ratios above 1.27 were 14.9 times more likely to result in injury than ACVR ratios below 1.27. CONCLUSIONS: Logistic regression reveals a significant relationship between ACVR and injury occurrence such that high ACVRs may increase injury risk.

Balancing nurses' workload in hospital wards: study protocol of developing a method to manage workload.

INTRODUCTION: Hospitals pursue different goals at the same time: excellent service to their patients, good quality care, operational excellence, retaining employees. This requires a good balance between patient needs and nursing staff. One way to ensure a proper fit between patient needs and nursing staff is to work with a workload management method. In our view, a nursing workload management method needs to have the following characteristics: easy to interpret; limited additional registration; applicable to different types of hospital wards; supported by nurses; covers all activities of nurses and suitable for prospective planning of nursing staff. At present, no such method is available. METHODS/ANALYSIS: The research follows several steps to come to a workload management method for staff nurses. First, a list of patient characteristics relevant to care time will be composed by performing a Delphi study among staff nurses. Next, a time study of nurses' activities will be carried out. The 2 can be combined to estimate care time per patient group and estimate the time nurses spend on non-patient-related activities. These 2 estimates can be combined and compared with available nursing resources: this gives an estimate of nurses' workload. The research will take place in an academic hospital in the Netherlands. 6 surgical wards will be included, capacity 15-30 beds. ETHICAL CONSIDERATIONS: The study protocol was submitted to the Medical Ethical Review Board of the University Medical Center (UMC) Utrecht and received a positive advice, protocol number 14-165/C. DISCUSSION: This method will be developed in close cooperation with staff nurses and ward management. The strong involvement of the end users will contribute to a broader support of the results. The method we will develop may also be useful for planning purposes; this is a strong advantage compared with existing methods, which tend to focus on retrospective analysis.