Analysis of Nursing Workload and Adverse Events in ICU: A Report

This report examines the impact of nursing workload on patient outcomes in the Intensive Care Unit (ICU), utilizing an evidence-based practice approach. The report analyzes a systematic review article focusing on the relationship between nursing workload and adverse events such as infections, pressure ulcers, and medication errors. The study employed various instruments, including the Nursing Activities Score (NAS) and the Therapeutic Intervention Scoring System (TISS), to measure workload. The literature search included databases like CINAHL, MEDLINE, and others, using the PICO strategy to formulate research questions. The review assessed the quality of included studies, using STROBE criteria. The results indicated a correlation between increased nursing workload and the occurrence of adverse events, with several studies highlighting the impact on patient outcomes. The report discusses the findings, methodologies, and instruments used, offering insights into the critical role of effective nursing management in ensuring patient safety within the ICU setting. The report emphasizes the need for monitoring nursing workload to ensure optimal patient care and reduce adverse events.

Evidence based
practice

INTRODUCTION
The patients admitted in intensive care unit require highly specialized care and attention.
It is required that health care professionals must deliver high quality services. The time
management and work balance plays significant role in affecting the incidences of adverse
events (Gomes, Cunha & de Oliveira, 2019). The most common and high vulnerable adverse
events includes infection risks, pressure ulcers, medication error, clinical negligence’s and fall
risk. There has been strong association between workload and management of adverse events in
the health care profession.
The nursing workload must be monitored daily within ICU so that patient safety can be
assured and proper staff sizing can be regulated. The lack of ineffective nursing management due
to engaged schedule leads to poor health outcomes of the critically ill patients. Their risk of
being vulnerable to adverse events is also increased. The report will analyse a secondary article
based upon this topic and clinical appraisal of chosen systematic article will be performed. The
chosen topic for the systematic review of article is significant as review of workload impact on
nursing practices within ICU can be life threatening for the patient and thus factor must be taken
into account.
Article chosen
Oliveria,. AC, Garcia,. PC & Nogueira LS,. 2016. Nursing workload and occurrence of adverse
events in intensive care: a systematic review. [Online]. Accessed through
<https://pdfs.semanticscholar.org/80e6/ec463c1f648422b81f2f2a4aa58919e052e5.pdf>
REVIEW PROBLEM
The chosen study has chosen adult patients which are admitted to ICU. Various types of
interventions are used in the study to measure the work efficiency of nurses and other research
variables. The study analyses and consist of interventions tools such as nursing activities score
(NAS) and therapeutic intervention scoring system to assess the workload of nurses in ICU
(Oliveria, Garcia & Nogueira 2016). From the secondary sources analysed in the chosen study
outcomes considered determines that these factors are protective considerations for the
prevalence and occurrence of AE. In the intensive care unit critically ill patients are treated. The
risk factors or the probability of such adverse events enhances among adults who may require
additional support due to higher age.
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The study outcomes also consider the factors such as financial barriers, increasing
number of patients and operational efficiency of nurses as critical aspect which causes failure to
meet the demands of nurses in ICU as per the desired extent. In order to support the literature
search the author has also explained the existing gaps in the literature and the research
progression of the topic in other fields. The quality of the study has been enhanced and improved
by providing support from different other researches as well. By comparing these external
resources the author has effectively highlighted the significance of the topic.
LITERATURE SEARCH
In the systematic literature review different databases such as CINAHL, MEDLINE,
BDENF, LILACS, Cochrane and SciELO are chosen by the authors. The study consists of
detailed synthesis of results on various themes. The data is collected from the electronic search
using these databases. In addition to these sources for enhancing the quality of research manual
searches and Google scholar are also used in the study for the analysis of grey literature. The
selection of adverse events for this study was also performed using similar search protocols. For
elaboration of the research questions one of the popular strategy related to the nursing called
PICO strategy has been taken in a study which stands for Patient, intervention, comparison and
outcomes. Both indexed and non-indexed descriptors were are used by the author to search for
the relevant studies appropriate for the research.
The author has also limited some aspects of the interventions used in the study. For
instance the comparison element of PICO strategy has not been addressed in the research
because study does not aim to compare any of the intervention. To assure that vast rage of
knowledge the author did not apply any filter criteria to the publication date. However boolean
operators such as “OR”, “AND” were used to adhere the inclusion and exclusion criteria of the
studies chosen in the literature review (Havaei, Mcphee & Dahinten, 2019). For each of the data
base author used different keywords which so that a huge range of quality studies can be
included in the research. The exclusion and inclusion criteria are used by the author, however the
given article does not specify these criteria in well-structured manner. A strong emphasis has
been provided on the literature search and keywords used for the research purpose. For the study
various keywords such as “care for adults in intensive care units”, “adverse health care event”,
“nursing workload and its impact on adverse event”, were searched.
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QUALITY OF THE REVIEW
One of the approach used by the author to enhance the quality of research is that author
assessed the quality of each study. The assessment also included the evaluation that if selected
studies satisfy inclusion and exclusion criteria. For avoiding any errors in the exclusion criteria
the studies which does not completely had data to serve inclusion criteria were also selected. The
data extraction from the articles was performed by instrument including variety of information
related to article. The information in this assessment tool consist of details such as author, title,
methodological design, country and year of publication, types of interventions used for
measurement of nursing workload, result, conclusion as well as type of adverse event analysed in
the study.
For enhancing the research quality two researchers applied instrumental STROBE criteria
which is Strengthening the reporting of observational studies in Epidemiology. These criteria
consist of a checklist which describes that which elements of observational studies must be
included and which must be excluded (Strazzieri‐Pulido, Padilha & Santos, 2019). Though
conclusive findings for the study are provided by combining the results of all studies. In the
chosen research the individual results of the studies are also taken into consideration. On the
basis of individual outcomes of the study all selected studies were grouped on the basis of
several criteria such as sample size or the type of adverse events. To strongly support the
arguments and conclusion of the study another approach used by the researchers in the study was
that various similarities of different studies were grouped together. It helped readers to analyse
the common trends supported by various researchers on the research subject.
However, the study did not consider the variations of results in detail. Though necessary
factors which lead to such variation in the research outcomes are effectively discussed in the
study. One of the characteristic attribute which enhances the effectiveness of the result is that for
each of the study code instrument of nursing workload mean (SD) is used to that similarities and
differences between outcomes of various study can be analysed. The systematic review provided
in the article consists of both qualitative and statistical data. Most of the studies used in the
systematic review are of prospective type.
Though this study design is costly and time taking but it serves the major advantage of
eliminating bias in conducting study. By using prospective study design more reliable results are
allowed and information limitations or the conceptual errors can be avoided. Due to use of
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prospectively collection of data the span of each study chosen in the systematic review was also
reduced. Along with the analysis of the chosen studies in the research the author also tried to use
data from the external sources such as health surveillance agency, health care standards and
regulations. It helped in exploring all possible aspects of the research subject. It has been
common that a very limited studies emphasis on relating nursing workload with the increased
deaths in ICU due to adverse events. The systematic review is critical in exploring such events
and their impact quality of patient health and safety outcomes .
RESULTS
The theoretical literature has been used in study. About 596 studies has been used in which
MEDILINE database has been found. Out of all studies only 38 potential studies has been
selected to reach at final result. For the selection of study first about 430 literature review has
been taken from google research and manual research. Then evaluation of their title and abstract
has been done after that some of them is selected to be readed in full and lastly out of 37 , 8
studies have been selected.
As a result none of the study has been found or shown agreement with STROBE.
However all research which has been used has showed 50% of items.
It has been seen in study that about 79 to 970 patients in ICU has been used as an sample.
Regarding the instrument of workload 3 studies has used nursing activities score (NAS). And
three has used TISS and two used project de Recherchie en Nursing (PRN) and Omega scoring
system.
Most of studies which was included in review shows that nursing workload increases on
occurrence of different AE: pressure ulcer, drug use and infection. The eight study which was
included gave different views. As per the first study in which sample size of 144 people is taken
as an sample, in the study it was analysed that sentimental incidents, death in ICU and
nosocomial infection (Hall & et.al., 2016). As a result it was found that about 33 deaths, 27
pressure ulcers and 14 incidents. The TISS values which is higher than 54 and 59 points. From
second study it was found that 144 patients was admitted to hospital due to MRSA and about 47
patients have acquired MRSA in the hospital.
While as per other study it was analysed that 39 patients has been found with MRB+. It
was found that there is relation between colonization and infection by MRB. The patient who
have been evaluated by MRB demanded more nursing workload than those who are without
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MRB. In fourth study sample of 7 people has been taken and it was found that there are about
230 adverse events related medication has occurred. The most frequently occurred is due to use
of an insulin pup. While as per fifth study it was found that 22 % patient has developed HAI in
ICU(Dobson & Dobson, 2018).
By analysing all the eight studies it can be seen that many infections and disease
occurrences which influence nursing workload. However the study has not used any type of
statistical analysis instead it has reviewed various studies to identify the influence of nursing
workload on the patient who have been admitted in ICU.
DISCUSSION
The authors has taken a review of various study related to nursing workload which will
help the local population. The study has helped in knowing various impacts of diseases on
nursing workload. From the study it was found that nursing workload creates an adverse event on
patients who are submitted in ICU. The various studies has applied the NAS and TISS
instruments for measuring nursing workload. The NAS which was developed by Miranda et,.al.,
in 2003 has analysed 23 items which is ranging from minimum weight of 1.2 to 32.0 maximum.
The total score of this is made up by directly summing up the points.
The instruments such as TISS and TISS-28 has been used in three studies. TISS
presupposed that more the patient health is serious than regardless of the diagnosis which was
presented the greater will be the number of interventions carried out. However this instrument
has undergone various improvements and the simplified version came as TISS-28, which analyse
28 items, which was divided into 7 activities such as cardiovascular support, neurologic support,
metabolic support, ventilatory support, renal support and specific intervention.
Omega and PRN is also applied in 2 study which was carried in Turkey in order to
analyse relationship among infection by MRB and nursing workload. Among all the studies
which has used NAS, all the studies has been carried in Brazil and has displayed mean value of
about 61.9% to 81.2%. When mean of NAS scores is compared to international studies, a totally
different results was found. On comparison it was found that 41 % was found in Spanish studies
and 95 % was found in Norwegian research. While one should look at the patient's clinical
characteristics and features of ICU as well as heterogeneity in application and principle while
looking at national and international literature.
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The overloaded on nursing work get influenced by an occurrence of AE which is related
to medication. From the study which was conducted in US it was found that each patient who
was admitted in country's hospital is susceptible to one medication error each day. And the study
which was conducted in Brazil on ICU patients about 550 AE has been identified and 283 was
duet to medication errors. It can be seen from the study that such type of Adverse Events in ICU
can be due to complexity of drug therapy and severity of clinical condition of patient.
The increase in such type of incident has developed the concern from Ministry of Health
who have along with NHS Agency, they have launched a safety protocol on prescription, use,
administration on medicine etc., for ensuring safe practices such as use of full name, signature,
date of birth, stamp, infusion of speed, identification of allergies. Also the protocol has also
recommended to use safe practices for storage and disposal of medicine (LoBiondo-Wood &
Haber, 2017). Therefore the studies has however created a good impact and has highlighted the
various isssues related to medications.
Only one study has influenced nursing workload on occurrence of AE due to fall of
hospital environment due to lack of quality of service provided to patient. The study has
highlighted that the fall in the hospital environment occurred due to lack of care and
unpredictable consequences to patients like lacerations, fractures, abrasions and confusions.
Despite of huge investments on devices for preventing and treating pressure ulcers, a high
incident of such events can be seen in patients who are hospitalized in critical care. The two
Brazilians has try to investigate influence of nursing workload on adverse event.
However many of the studies is of prospective type. This type of method is however
costly and time consuming but using this method is advantageous as it give less bias results. The
reason behind this is that basic variables for example lack of information can be managed and
more trustworthy results can be allowed.
As per the author views most of the study which has been reviewed showed nursing
workload, and has also analysed various different instruments and how it has an impact of
occurrence of critical or harmfuls events on patients while a patient is hospitalized in ICU. As
per the literature adverse events influence quality care with the increase in rate of mortality,
higher welfare cost and longer hospital state.
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Therefore analysis of workload of nursing is required in order to built a relation between
patients and nursing professionals which can be done by focusing on prevention of AE and
patient safety.
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REFERENCES
Books and Journals
Dobson, D., & Dobson, K. S. (2018). Evidence-based practice of cognitive-behavioral therapy.
Guilford Publications.
Gomes, F.A., Cunha, T.M. & de Oliveira, R., (2019). The nursing workload assessed through the
Nursing Activities Score as a predictor for the occurrence of ventilator-associated
pneumonia in an adult intensive care unit. Journal of Nursing Education and
Practice, 9(9).
Hall, L. H. & et.al., (2016). Healthcare staff wellbeing, burnout, and patient safety: a systematic
review. PloS one, 11(7). e0159015.
Havaei, F., Mcphee, M., & Dahinten, V. S. (2019). The effect of nursing care delivery models on
quality and safety outcomes of care: A cross‐sectional survey study of medical‐surgical
nurses. Journal of advanced nursing.
LoBiondo-Wood, G., & Haber, J. (2017). Nursing research-E-book: methods and critical
appraisal for evidence-based practice. Elsevier Health Sciences.
Strazzieri‐Pulido, Padilha, K.G. & G. Santos, V.L., (2019). Pressure injuries in critical patients:
Incidence, patient‐associated factors, and nursing workload. Journal of nursing
management, 27(2), pp.301-310.
Online:
Oliveria., AC, Garcia., PC & Nogueira LS., (2016). Nursing workload and occurrence of adverse
events in intensive care: a systematic review. [Online]. Accessed through
<https://pdfs.semanticscholar.org/80e6/ec463c1f648422b81f2f2a4aa58919e052e5.pdf>
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