Category: Intensive Care

An intensive care unit (ICU) is a special section of hospital that offers continuously specialized care for critically ill patients. The purpose of intensive care unit is to give the required care to its patients at all times. Healthcare providers assign duties to workers or interns who carry out round the clock intensive monitoring and treatment of the critically ill patients (Krubholz & Masoudi, 2006). Intensive care unit offers relief to patients suffering from a potentially life threatening illness, hence the necessity to ensure approach to care is observed with maximum caution. There are special equipments and monitoring devises required for a complete provision of care for ICU patients. It is a common practice that ICU units tend to limit the number of visitors even during the allocated visiting hours. The patient’s cardiac status, breathing rates, blood levels and urinary out put are assessed frequently by the healthcare professionals, so as to analyze if there is a problem that requires urgent attention. Those who have been operated on are provided with special equipments to facilitate their recovery process. For instance, these patients are provided with specific equipments that can detect blood pressure fluctuations like the catheters. They normally have their breathing rates under monitor and necessary mechanical support is given through ventilators and tubes in case some anomalies are detected. Patients in intensive care units are also offered with alarms that operate incase a patient’s vital signs elapses. For example, changes in heartbeat rate and blood pressure can be checked through this process.

Visiting hours are meant to allow people to come in to check on how the patients cope on with treatment. It is done with particular procedure and at a particular time. For example ,visiting hours may be from 7.00am to 9.00pm in some hospitals ,while in others may be restricted for only a short period of time like from 5.00pm to 6.00pm.

Having visiting hours in the intensive care unit is advantageous in many ways. First, patients try to show some positive responses such as reduced blood pressure and heart rates, consequently leading to a potential decrease in blood sugar level (Plowright, 2006). The visiting effect has a psychological impact on the patient’s mental thinking, as close family members and friends’ closeness during visit offers sense of love and joy (Plowright, 2006). Patients always feel happy and comfortable when they see one or more of their relatives and friends sit next to them and give them word of hope and encouragement. Such gestures from family members and relatives make patients feel loved and cared for, thus bringing a sigh of relief amidst the inherent pain.

Visiting hours have also been found to be beneficial to the family members. Family members and friends, generally referred to as significant others, often feel worried, hopeless, helpless and uncomfortable about the situation their loved one has been subjected to (Farrell, Joseph & Schwartz- Barcott, 2006). A common observation suggest that once the patient has been admitted into the hospital’s ICU, family members and friends are often left with little information about on progress. In such a case, the only way they would be assured of the patient’s status and progress is by providing them with visiting hours; a period in which they can get updated, and even be in position to update the ICU care staff of what they feel is important for complete care. A family member selected to visit the patient will be in position to give feedback concerning the patient to the rest of the family members and friends. Therefore, visiting hours in intensive care units is very necessary to both the patients, and friends and family members.

Studies show that family members often have important information at their disposal during visits. The information concerning patients admitted in ICU has been found to be useful in the diagnosis and treatment process. For example, a patient may have undergone a life threatening experience in the past, but the family members present during admission fail to mention such a case, subsequently leading to misinformation. Allowing family members and friends to visit have therefore been found to give them opportunity to recall some of those experiences, significantly helping the medical team to adjust their treatment plan where necessary (Ismail, 2007). The medical team is also in a position to increase surveillance on the patient, so as to establish whether there’s need for special treatment for the latter.

It is noted that patients who have been admitted in the intensive care units are facing the most critical stage of their lives, often finding themselves stressed up and disillusioned. Having visiting hours in the ICU is very useful and important to the patient’s therapeutic process of healing. Moreover, it is treated as a human rights requirement, accorded to the patient and his family members during the most critical moment in life (Lee, Friedenberg & Mukpo, 2007). This period enables family to have the needed chance to provide necessary input into the sick person’s care, such as involving themselves in the healing process of the patient through psychological support. It also builds trust between the patient and hospital staff in charge.

However, there are several disadvantages of visiting hours. Chief among them is the privacy and confidentiality issue. It is noted that some procedures performed on patients are so confidential, that allowing individuals outside the medical team may be impractical. In some cases, the patient may be in a very critical condition that he /she is unable to talk, but does not want to see people around him or her. Such a scenario may lower the patient’s self esteem and even worsen his /her health condition if visitors are allowed in. In certain incidences, visiting hours have been found to interfere with a patient’s rest (Tanner, 2005). Specifically, this affects patients who have experienced critical injury; and requires enough rest to gain the needed strength for healing process. Such patients do not want disturbance, as this irritates them and subsequently lowers their ability of recover. Moreover, visiting family members and friends may be bothering the patient with unending questions, some of which may be sound insensitive. The anxiety on the side of the visiting family members and friends may lead irritation, as the patient would be required to repeat issues over and over, thus denying the patient enough rest, increase the stress level, subsequently prolonging his or her healing process.

The other group that is highly affected by the visiting hours is healthcare providers and their staff. Family members and friends have been noted to put a lot of pressure and sometimes give orders to the nurse in charge or the doctor on how things should be done, ostensibly assuming the roles and abilities of these specialists. According to Tanner (2005), such cases leave nurses attending to the patient with the feeling of worthlessness, psychologically jeopardizing treatment process. One qualitative study showed that in some incident, a nurse in charge never returned to the ICU room until the visitors had left; just to avoid being ‘tossed here and there’. Some visitors have also been found to break the rules such living their mobile phones on during the visit, consequently going against the regulations set. A ringing phone has been found to have irritating impact on the sick. In some cases, the patient may need an emergency attention during visiting hours, a process that can be tricky as family members may not notice when a medical staff is not accompanying them. Therefore; visiting hours should depend on individual patient’s willingness, medical team recommendation, and the overall status of the patient needs.

Visiting hours have a great advantage in the intensive care unit because it makes the patients to know that they are loved and taken care of by their relatives especially during critical moments. Moreover, it boosts patient’s morale in life, through the psychological support given by family members, thus act as stepping stone to the patient’s healing process. However, this time also has some disadvantages, especially when a proper plan is not in place. It can result into distractions to both the critically ill person and the healthcare providers. Therefore, visitation process should be a decision made by the patient himself if they are in position to talk. It should also be limited to a certain level to avoid confusion and disruptions in a patient’s rest time, which is known to facilitate recovery process. However, the most important thing is to ensure a proper plan, entails medical team and a patient’s views, is put in to place so that it does not interfere with other medical plans scheduled for the patient.

Reference List

Farrell, M., Joseph, D., & Schwartz- Barcott, D. (2006). Visiting Hours in the ICU: Finding the balance among patients, visitors and staff needs. Nursing Forum, 40 (1), 18-28.

Ismail, S. (2007). Visiting times: History, BMJ 101 (17): 58-85.

Krubholz, M., & Masoudi, F. (2006). The year in epidemiology, health services research, and outcomes research. Journal of the American College of Cardiology, 48(9), 1886- 1895.

Lee, D., Friedenberg, S., & Mukpo, H. (2007). Visiting hours policies in New England intensive care units: strategies for improvement. Critical Care Medicine, 35(2): 497-501.

Plowright C. (2006). Just who actually benefits from restricted visiting hours is not clear. Nurs Times, 102(47):12.

Tanner J. (2005).Visiting time preferences of patients, visitors and staff. Nurs Times, 101(27):38-42.

Introduction

The problems of nurse shortages and inadequate staffing remain to be serious in the healthcare institutions in the United States and globally. The issue requires further discussion because researchers point to the relationship between the workforce size and mortality of patients in hospitals, and this problem is one of the most challenging questions in nursing. In their article “Nurse Staffing, Medical Staffing and Mortality in Intensive Care: An Observational Study”, West et al. (2014) described the results of the quantitative observational study aimed at exploring the above-mentioned issue. The purpose of this paper is to provide a critical analysis of the article with a focus on its effectiveness and significance to the field of nursing.

Research Problem and Purpose

Patients with severe diseases and those who have no assistance from the family are often treated in intensive care units (ICUs). However, the problem is in the fact that ICUs should be well-staffed to provide high-quality care, but the costs of hiring an adequate number of staff are high. Focusing on the aspect of the disparity between the required staff-patient ratio and ICUs’ actual staff policies, West et al. (2014) concentrated on the problem of the relationship between the staffing approach in ICUs and patient outcomes or mortality. The researchers noted that the previous studies were mainly qualitative, and they did not demonstrate the actual relationship, or they argued that ICUs had no problems with staffing. West et al. (2014) observed the situation in discussing the problem with the focus on possible gaps. They formulated the purpose of the research that was to explore the relationship between the staff number in ICUs and the level of mortality or patients’ “survival chances” (West et al., 2014, p. 782). The rationale for the research was also supported by the statement that the main evidence on the topic was presented in the studies by only a few investigators from the United States. Therefore, the study aimed at contributing to the existing knowledge in the area of nursing.

Research Questions and Hypotheses

Instead of presenting the research questions, West et al. (2014) focused on formulating hypotheses based on the literature review. In order to discuss the contribution of different types of personnel to the survival of patients in ICUs, the researchers provided different hypotheses for the relationship between the number of nurses and rates of patient mortality, the number of consultants and rates of mortality, and the number of support staff and mortality. The hypotheses were based on the assumption that the higher number of different specialists working in an ICU is related to the lower rates of mortality among severely ill patients. The final hypothesis was formulated to explore the relationship between the workload and the survival rates. The decision to investigate the studied relationship separately for different groups of the staff can be discussed as effective to assist in understanding the role of nurses in influencing the patient mortality rates when the staffing policy is not appropriate.

Theoretical Framework and Study Variables

The researchers identified the patient mortality rates in ICUs as the dependent variable, but to overcome the bias and uncertainties in the results, West et al. (2014) also identified the risk adjustment factors to exclude the aspects that could influence the patients’ death without the focus on the staffing problem. Independent variables were determined according to the hypotheses, and they included the specific “number of nurses per bed,” the number of consultants, the presence of an intensivist, and the presence of the support staff (West et al., 2014, p. 786). To receive the most accurate results, the researchers chose to divide the important variable measuring the number of nurses per bed into two variables to focus on differences among direct care nurses and supernumerary nurses. The overall framework and identified variables can be viewed as effective to study the aimed relationships to provide reliable results.

Review of Literature

West et al. (2014) indicated the literature review as the discussion of the previous literature on the topic at the beginning of the article. The researchers examined 50 articles, among which only 11 articles reported the studies conducted within the 2009-2014 years. However, the researchers cited the seminal papers that influenced the further discussion of the topic by investigators. The literature was divided into such categories as articles on nurse staffing, medical staffing, and workload. This approach allowed the detailed discussion of aspects of the problem. Concentrating on the nurse staff problem, the authors referred to articles written by the American, English, Korean, and Belgian authors to demonstrate the international role of the issue (Cho, Hwang, & Kim, 2008; Kane, Shamliyan, Mueller, Duval, & Wilt, 2007; Tourangeau, Doran, Hall, & O’Brien Pallas, 2007; Van den Heede, Sermeus, Diya, & Clarke, 2009). However, the researchers noted that the majority of reviewed studies were qualitative, and they did not provide effective evidence to prove or reject the idea of the relationship between nurse staffing and patient mortality rates. The authors also examined the literature on the medical staff and workload in ICUs in detail, and it was found that the previous studies failed to demonstrate the role of the medical workforce and workload in affecting patient mortality in ICUs with references to the effective data (Griffiths, Jones, & Bottle, 2013). From this point, West et al. (2014) concentrated on overcoming the gap in the existing research on the topic.

Methodology, Sample, Setting, and Extraneous Variables

West et al. (2014) selected the quantitative methodology to complete the cross-sectional observational study that was retrospective in its nature. The cross-sectional observational studies are usually descriptive, and they are effective to examine the relationship between the factors and outcomes during a certain period (Keele, 2010). The method is appropriate to test the hypotheses. However, the sampling approach selected by the researchers can be viewed as rather inefficient to provide credible results. Even though the researchers focused on the national sampling frame and used the UK National Research Centre data on more than 38,000 patients registered in 65 ICUs, as well as on nurse and medical staffing in those facilities, the data were related to 1998, and they can be inappropriate to represent the current situation in the field. From this point, the strengths of the method and sampling include the possibilities to use the data referred to the large sample size, but weaknesses are associated with the use of rather outdated information that cannot illustrate the modern situation in ICUs. The other limiting factors are extraneous variables that can influence the results and add to the number of study errors (Hackshaw, 2015). To eliminate the effect of extraneous variables, West et al. (2014) focused on the additional analysis and control of such causes of patient mortality in ICUs as the patient’s age, the severity of the disease, and other risk factors. This approach contributed to decreasing the level of bias.

Measurement and Data Collection

The data for the analysis were collected from two sources, including the data of the Intensive Care National Audit and Research Centre on patient mortality in the United Kingdom and the data of the Audit Commission on the staffing in ICUs and hospitals. The researchers decided to collect the data for both types of healthcare institutions related to the period of 1998 to compare the results and prove the credibility of conclusions regarding ICUs. These data were important to discuss the case of transferring patients from ICUs to hospitals. It was critical to determine the measures of the variables, and the dependent variable of the patient mortality was assessed with references to the length of patients’ staying in ICUs and hospitals and the regular number of admissions. The number of transfers was also considered. This approach can be discussed as effective to measure the aimed variable (Harrison, Parry, Carpenter, Short, & Rowan, 2007). In addition, the measurement of the risk adjustment variable was added to reduce the bias. The authors discussed the measurement of independent variables while presenting the rationale for selecting them for the study. It was noted that participation in the study was voluntary, and the use of the data was agreed with the National Research Centre.

Analysis and Results

The multilevel regression was utilized to conduct the statistical analysis of the collected data. The appropriateness of the chosen statistical method to study the observations as unity is proved with references to the previous studies in the field (Gelman & Hill, 2006). It was found that more than 16% of patients died in the ICU in 1998, and more than 11% of patients died in the hospital after they were transferred from ICUs. The comparison of the mortality rates in ICUs and hospitals demonstrated that the rate was up to 34% in certain ICUs, and it was up to 48% in certain hospitals. The further analysis indicated that the highest level of mortality was in ICUs and hospitals with the lowest size of the nurse and medical staff. The researchers also found that the nurse-patient ratio played a more important role in influencing the patient’s survival than the presence of consultants. The researchers made an important conclusion that the support staff size was not statically significant to influence the patient mortality. West et al. (2014) also analyzed the role of the undesired factors to influence mortality, and the hypothesis regarding the positive relationship between the workload and patient mortality was also supported. The data analysis method was selected effectively to test the relationships, and the results allow the further calculations to predict how increases in the number of nurse staff can contribute to reducing the patient mortality rates.

Strengths and Limitations

It is possible to determine two main strengths associated with the study. The first one is the reliance on credible data related to the large sample of participants, ICUs, and hospitals. The other strength of the research is the use of effective data analysis methods to examine the relationships in these complex data. From this point, the researchers effectively chose the sample size, the source of the data, and the analytical tools. However, the study has limitations. The main limitation is the use of the data related to 1998. It is possible to expect that the staff size in the majority of researched ICUs changed under the impact of internal and external factors, including the healthcare policies. From this point, the practical value of the study is decreased. The other limitation is associated with the application of the cross-sectional study pattern instead of the longitudinal one because longitudinal studies can provide more valid results regarding the relationship between the determined variables.

Implications, Conclusions, Recommendations

The review of the literature and study results indicates that further research on the topic is possible. West et al. (2014) chose to analyze the relationship between the number of nurses and patient mortality in ICUs along with examining the relationship between the number of other medical and support staff and patient outcomes. These relationships were analyzed separately, but it is possible to assume that the impact of the combined nurse and medical staff’s assistance on the patients’ survival can also be observed. It is important to further research the role of the nursing staff in affecting the patients’ survival and the role of the medical staff’s professionalism in influencing the patients’ outcomes, as it was noted in previous studies (Kim, Bernato, Angus, Fleisher, & Kahn, 2010; Needleman, Buerhaus, Pankratz, Leibson, & Stevens, 2011). The researchers can study how the teamwork of nurses and physicians can contribute to increasing the chances of the patients’ survival and how many nurses should be scheduled for the shift to address the patients’ needs depending on the workload. The study of the nurse role is important in this case, and it is also necessary to focus on examining the workload effects on patient mortality.

The study results indicate that there is a direct positive relationship between the adequate high number of the nurse staff and medical staff and the high level of patients’ survival in ICUs. There is also a positive relationship between the high workload and the high patient mortality. The overall contribution of the study to the nursing field is significant, but the results are important to be used as the theoretical background for discussing the relationship between the principles of nurse staffing and the actual patient outcomes, including the rate of survival for severely ill patients or the rate of mortality. Still, the results provided by West et al. (2014) are not effective to be utilized in practice because they are general and based on outdated data sources.

The researchers also recommend using their findings in theoretical and qualitative studies. In addition, it is possible to recommend testing the findings with references to the severely ill patients in ICUs while discussing them as the group of persons who are highly dependent on the size of the nurse staff in the facility. Further studies should also include the focus on the other influential factors that were excluded in this study. It is also recommended to test the suggestion that the decreased workload in ICUs and the increased number of nurses can positively affect the high survival rates.

References

Cho, S. H., Hwang, J. H., & Kim, J. (2008). Nurse staffing and patient mortality in intensive care units. Nursing Research, 57(5), 322-330.

Gelman, A., & Hill, J. (2006). Data analysis using regression and multilevel/hierarchical models. Cambridge, UK: Cambridge University Press.

Griffiths, P., Jones, S., & Bottle, A. (2013). Is “failure to rescue” derived from administrative data in England a nurse sensitive patient safety indicator for surgical care? International Journal of Nursing Studies, 50(2), 292–300.

Hackshaw, A. (2015). A concise guide to observational studies in healthcare. New York, NY: John Wiley & Sons.

Harrison, D. A., Parry, G. J., Carpenter, J. R., Short, A., & Rowan, K. (2007). A new risk prediction model for critical care: The Intensive Care National Audit and Research Centre (ICNARC) model. Critical Care Medicine, 35(1), 1091–1098.

Kane, R. L., Shamliyan, T. A., Mueller, C., Duval, S., & Wilt, T. J. (2007). Nursing staffing and quality of patient care. Medical Care, 45(12), 1195–1204.

Keele, R. (2010). Nursing research and evidence-based practice. New York, NY: Jones & Bartlett Learning.

Kim, M. M., Bernato, A. E., Angus, D. C., Fleisher, L. F., & Kahn, J. M. (2010). The effect of multidisciplinary teams on Intensive Care Unit mortality. Archives of Internal Medicine, 170(4), 369-376.

Needleman, J., Buerhaus, P., Pankratz, S., Leibson, C. L., & Stevens, S. R. (2011). Nurse staffing and inpatient hospital mortality. New England Journal of Medicine, 364(1), 11-18.

Tourangeau, A. E., Doran, D. M., Hall, L. M., & O’Brien Pallas, L. (2007). Impact of hospital nursing care on 30‐day mortality for acute medical patients. Journal of Advanced Nursing, 57(1), 32-44.

Van den Heede, K., Sermeus, W., Diya, L., & Clarke, S. P., (2009). Nurse staffing and patient outcomes in Belgian acute hospitals: cross-sectional analysis of administrative data. International Journal of Nursing Studies, 46(7), 928–939.

West, E., Barron, D. N., Harrison, D., Rafferty, A. M., Rowan, K., & Sanderson, C. (2014). Nurse staffing, medical staffing and mortality in Intensive Care: An observational study. International Journal of Nursing Studies, 51(5), 781-794.

Abstract

If not treated timely, cardiac arrest presents a significant problem for patients in the intensive care unit (ICU). Nurses’ skills and use of advanced knowledge greatly influence cardiopulmonary resuscitation – the use of capnography, for example, is considered to improve CPR results. The purpose of this quantitative, quasi-experimental pretest-posttest project is to determine to what degree the implementation of capnography during cardiopulmonary resuscitation (CPR) when compared to the current practice would impact nurses and increase the use of capnography during CPR for adult ICU patients at an acute care hospital in New Jersey. The project is based on Lewin’s change theory; the author proposes that any change process has three main steps: unfreeze, change, and refreeze. The quantitative methodology was selected due to its ability to address clinical questions with meaningful, quantifiable, and transparent results. The project utilizes a quasi-experimental design to choose the sample and manipulate the independent variable, the nursing training program of capnography use during CPR, to influence the dependent variable, the number of CPR cases with the use of capnography. The population under investigation is adult patients who had a cardiac arrest and underwent CPR while in the ICU. The data, obtained from the Nurses’ Knowledge on Capnography Test and EHR, were analyzed with a paired sample t-test and Gain’s score to note pretest-posttest differences in nurses’ use of capnography before and after training. [data results and implications to be added later]

Introduction to the Project

Nurses’ knowledge pertaining to clinical devices used for monitoring, assessing, and treating patients with heart conditions is an important factor for achieving quality of patient care and organizational effectiveness (Cook & Harrop-Griffiths, 2019). Studies conducted by Linet al. (2017), Novais and Moreira (2015), and Pantazopoulos et al. (2015) alluded to the lack of knowledge among nurses in using capnography as recommended by the Advanced Cardiac Life Support (ACLS) to capture pertinent information about a patient’s end-tidal carbon dioxide (ETCO2) condition.

They found that such low awareness of this approach presents uncertainties and poor clinical monitoring practices. Low-quality nursing practices are exemplified by the lack of awareness in using capnography; especially, when success in patient care is dependent upon the practice knowledge and use of innovative devices such as capnography in a clinical setting (Hamrick et al., 2017).

In another study, Hamrick et al. (2017), Heradstveit and Heltne (2014), and Kodali and Urman (2014) linked the importance of using capnography in monitoring and gathering patient information during cardiopulmonary resuscitation events to the critical role of nursing practitioners and the knowledge in using capnography to improve patient quality care.

The scholarly debate persists regarding the complexities in instituting clinical monitoring devices in the clinical setting and the lack of knowledge to effectively use the device. The rationale for this project lies in its potential beneficial effects on increasing the use of capnography in the intensive care unit (ICU) setting. Finally, the findings presented could be used to enhance the awareness about the project and its objectives.

Background of the Project

Cardiac arrest poses a significant threat to patients in intensive care units and is a significant factor that can subsequently lead to a patient’s demise if not addressed timely (Hartmann, Farris, Di Gennaro, & Roberts, 2015). As a result, the use of capnography to improve the outcomes of patients during cardiac arrests has been widely studied in the literature (Edelsonet al., 2014; Mader, Coute, Kellogg, & Harris, 2014). According to Cereceda-Sánchez and Molina-Mula (2017), capnography has been developed as a measurement for monitoring coronary perfusion pressure (CPP) and coronary blood flow.

Recent studies have shown the effectiveness of capnography in patients’ treatment with chronic hypercapnic respiratory failure, hypoventilation, severe hypothermia, and metabolic changes clinical (Darocha et al., 2017; Cereceda-Sánchez & Molina-Mula, 2017; Chhajed et al., 2016). However, Leppink, O’Sullivan, and Winston (2016) noted that despite the existence and widespread use of capnography in practice improvement, many nurses still show some levels of uncertainty due to the reduced awareness in the knowledge and application of capnography in clinical settings.

Recent studies conducted by Dioso (2014) and Duckworth (2017) amplified the importance of equipping nurses with the knowledge of the application of capnography as a technique to manage cardiac arrest incidence amongst patients. This training approach should address knowledge barriers about capnography and its applications in improving the patient’s quality of care (Israel, 2014; Jaffe, 2017; Kuisma et al., 2017; Nassar & Schmidt, 2016). The strategic application of capnography is to improve patient care, and the paradigm shifts are often conflicted among nurses introduced to clinical monitoring tools such as capnography.

The major concern for healthcare practitioners is to minimize the negative impact created by the uncertainties and the lack of knowledge by nurses in using capnography. This relationship between nurses’ adoption of capnography, clinical uncertainty, lack of knowledge to use capnography in clinical settings, and its impact on patient care remains understudied (Kodali, 2013; Whitaker & Benson, 2016). Additionally, Sandroni, De Santis, and D’Arrigo (2018) argued that the lack of knowledge among users monitoring such as capnography could result in fatality.

The scholars also uncovered a gap in the literature pertaining to nursing practices in the use of this monitoring device to minimize medical errors in a clinical setting, as well as nurses’ adoption of capnography, clinical uncertainty, and the lack of knowledge for using capnography in a clinical setting. Further investigation, as described herein, could expand the understanding of the nurses’ role in adopting capnography and investigate the levels of clinical uncertainties resulting from the lack of device monitoring knowledge in the healthcare industry.

Problem Statement

It is not known to what degree the implementation of an evidence-based intervention impacts the use of capnography during CPR, when compared to current practice among adult ICU patients undergoing cardiopulmonary resuscitation in the ICU. Previous studies conducted by Hassankhani, Aghdam, Rahmani, and Mohammadpoorfard, (2015) and Kiekkas, Stefanopoulos, Konstantinou, Bakalis, and Aretha (2016) showed that nursing practice pertaining to the application of evidence-based technology such as capnography is essential in managing cardiac-related incidents.

In addition to the above mentioned studies, the perception exists that if nurses possess sufficient knowledge pertaining to the use of capnography during cardiopulmonary resuscitation (CPR), they can achieve better outcomes for the patient; especially in monitoring patients heart conditions and reducing risks of complications during a direct peritoneal resuscitation (DPR) (Hassankhani et al., 2015). The general clinical problem in nursing practice is the lack of knowledge about how to use new innovations such as capnography. Specifically, the clinical problem in this project is that managers do not understand the relationship between nurses’ adoption of capnography, clinical uncertainty, and the lack of knowledge to use capnography in a clinical setting.

To that extent, it is not apparent if or to what degree the implementation of an education and a standardized process for the use of capnography during CPR with nurses from a 20 bed ICU (8-10 bed capacity) at a 240-bed acute care hospital in New Jersey, would impact the rate of use of capnography during CPR when compared to current practice among patients undergoing cardiopulmonary resuscitation in the ICU. It is also not clear whether the nurses’ lack of knowledge impedes the application of capnography in clinical settings (Kiekkaset al., 2016). Therefore, these pressing questions will become the center of this project.

Purpose of the Project

The purpose of this quantitative, quasi-experimental pretest-posttest project is to determine to what degree the implementation of capnography during cardiopulmonary resuscitation (CPR) when compared to the current practice would impact nurses and increase use of capnography during CPR for adult ICU patients at an acute care hospital in New Jersey. The independent variable identified in this project is the intervention program designed to improve nurses’ knowledge of capnography use. The dependent variable is the number of instances of the use of capnography during resuscitation. The nurses practicing in the United States at clinical centers within or around New Jersey will be the target population for this project. The selected sample group will be appropriate for the project because of their clinical exposure to the use of capnography.

In examining the level of knowledge, this project will be focused on ascertaining the strength, vulnerabilities, and weaknesses specific to the nursing awareness about the use of capnography during cardiopulmonary resuscitation. Additionally, the author of the project will attempt to examine the correlation between such knowledge and the use of capnography during CPR and determine if any connections exist between nursing knowledge and their resistance against the use of capnography in the cases of CPR.

In addition to addressing the dearth or deficiencies in research on this topic as it pertains to the scholarly work and as well as the necessary insight for clinical managers, this project will also attempt to provide some understanding of the differences in the nursing knowledge in using capnography during cardiopulmonary resuscitation. Moreover, it will offer new information to achieve efficiency in the adoption of capnography in managing patients with CPR. The outcomes of this project include a positive clinical nursing practice change in which clinical managers use the results of the initiative to moderate nurses’ adoption of clinical devices in the hospital setting.

Clinical Question

The use of capnography by nurses is a strategic approach to achieving positive clinical outcomes. It has been discussed previously that the lack of knowledge and the inability of nurses to adopt innovation such as capnography can result in unintended consequences such as clinical uncertainties, medical error, and even patient fatality in a clinical setting. The central clinical question that guides this project is:

To what degree does implementation of an evidence-based intervention on use of capnography during cardiopulmonary resuscitation (CPR) impact use of capnography during CPR when compared to current practice, among adult ICU patients in an acute care hospital setting in New Jersey within a four-week period?

Advancing Scientific Knowledge

The outcome of the proposed project could contribute to the development of population health outcomes of patients suffering from cardiovascular diseases. This will be accomplished by the abilities of the investigator to provide clinical practice evidence pertaining to the results of the project and its effect on coronary care. The findings in the proposed quantitative pre-test post-test study could be used by clinical managers to moderate nursing practices in the adoption of new clinical devices such as capnography. Edelson et al. (2014), estimated that over 200,000 people suffer cardiac arrest annually, and more than 80% of them do not survive to discharge (p. 353). Kodali and Urman (2014), and Mader et al. (2014) found that thousands of people die from cardiac arrest in the United States every day. It appears from these numbers that cardiac arrest is a common problem the continues to affect various demographic populations in the United States. Thus, the proposed project is relevant and important to the current sphere of medical science.

Studies by Kiekkas (2016) and Lui, Poon, and Tsui (2016) advanced the knowledge for the use of capnography in the clinical settings to monitor and improve survival rates of cardiac-related incidents. However, the research outcomes surrounding the cases in which nurses lack the knowledge to use capnography have proven to be inconsistent, thus creating difficulties and uncertainties for targeted practice improvement measures (Dioso, 2014). To improve capnography practices in clinical settings, nurses and clinical managers must understand the relationship and importance of using capnography to improve patient outcomes. This project has the opportunity to close the gap in the information about nurses’ adoption of capnography, clinical uncertainty, and the lack of knowledge to use capnography in a clinical setting. It is also a contribution to the larger body of literature and application to nursing practices.

The theoretical foundation for the study will be based on the model of change introduced by Kurt Lewin in the 1940s. The author’s theory proposes that all change projects happen in three steps – unfreezing, moving, and refreezing (Lewis, 1951). Lewis (2003) further that each stage is invaluable, meaning that they all play a role in the new structure or objective becoming a part of the existing system. This theory implies that people are resistant to change, especially if they do not understand why it is necessary (Burnes & Bargal, 2017). Moreover, the process of a change’s introduction can be influenced by using the elements outlined in the “unfreeze” step.

Lewin’s (1952) view of change projects will provide a helpful concept to explain the processes and ideas relating to the adoption of new techniques, applications, and systems in varieties of organizational settings such as health care centers. In the case of nursing knowledge and capnography, this theory demonstrates that the complexity of an innovation and its compatibility with the existing system are crucial in the success of its implementation. Thus, the project that targets nursing training can use this approach to measure the correlation between knowledge and use of the procedure and provide insight into nurses’ changing attitudes towards capnography in CPR.

Significance of the Project

From current observation, it is not known whether increased nurses’ knowledge of capnography is associated with the increased use of capnography during cardiopulmonary resuscitation. The significance of the project lies primarily in addressing the inconsistent findings in the scholarly literature on capnography and nurses’ knowledge regarding its use during cardiopulmonary resuscitation (CPR) in the intensive care unit. The studies discussed above, including those by Kodali (2013) and Whitaker and Benson (2016), show that there exists a gap in understanding how nurses’ awareness of capnography affects their choice of using it during CPR. Furthermore, as evidenced by the analysis of current research, articles on capnography focus mostly on the outcomes and implementation of capnography within this healthcare setting (Kalmar et al., 2018; Langhan, Shabanova, Li, Bernstein, & Shapiro, 2015; Turle, Sherren, Nicholson, Callaghan, & Shepherd, 2015). To facilitate the effective use of capnography, it is essential to determine individual factors that impact nurses’ knowledge and the understanding behind the readiness to use capnography into practice.

This project aims to explore the link between nurses’ knowledge and the use of capnography during CPR further, thus providing the basis for further practice improvement and future scholarly work in this area. The results of this initiative could also lead to the improvement of practice approaches in capnography and an enhancement in the quality of patient outcomes in the intensive care unit setting. This project differs from other studies in the field of capnography use in terms of its focus, while it also builds on other research concerning the nurses’ perspectives on capnography and its importance in promoting successful patient outcomes (Lin et al., 2017; Novais &Moreira, 2015; Pantazopoulos et al., 2015).

Furthermore, the project fills in the gaps pertaining to the literature reviews on the topic by correlating them with the data provided by quantitative studies of capnography and the nurses’ knowledge of the topic as well as its application within the present intensive care unit setting. The critical implications of the project exist for a variety of stakeholders, including nurses, managers, patients, and the industry as a whole. The results of the data collected during this project’s duration rely on practice improvements in education and training. This, in turn, would contribute to population health by enhancing clinical practices in CPR and the improvement of capnography efforts within this setting. Also, it would decrease uncertainty during resuscitation procedures and practices that can stem from a lack of knowledge by nurses, reducing stress and promoting guideline compliance within the intensive care unit. Overall, the project would add value by providing information in support of nursing education and training in capnography, which would help to advance the practice and improve population health.

Rationale for Methodology

The quantitative method was chosen for this project due to its features in addressing clinical questions using the collection of meaningful information on the capnography use and nurses’ knowledge. In this quantitative methodology, data gathering will be the primary strategy for getting information from the project participants (Kiekkas et al., 2016). The quantitative method was considered for this project because the investigator needed to examine the relationships between individual factors affecting capnography use and nurses’ knowledge during cardiopulmonary resuscitation (CPR) practice in intensive care units. Quantitative methodologies have many benefits that are relevant to this project. They provide a high level of validity and certainty of results as they apply statistical tools for data gathering, organization, and analysis. (Ali & Bhaskar, 2016; Center for Innovation in Research and Teaching, 2013a; Heale & Twycross, 2015; Leppink et al., 2016; Watson, 2015). The use of the quantitative method in this project will be strategic in answering the formulated clinical question to clarify and provide some insight to underlying phenomena in the variables proposed in the study (Campbell, 2017; Center for Innovation in Research and Teaching, 2013b; Guo et al., 2016; Nelson, 2018).

The qualitative methodology will not be used in this project because it contains some limitations that could possibly influence and hinder the reliability of data findings. Qualitative methods are concerned with abstract concepts, and thus their ability to provide objective information is limited (Flick, 2018; Green & Thorogood2018). This is one of the core concepts behind their use and their limitations in understanding the participants’ behaviors and attitudes rather than specific activities, or knowledge levels can affect the results of the data (Austin & Sutton, 2014; Barnham, 2015; Flanagan, Greenfield, Coad, & Neilson, 2015; Gunnell, 2016). In addition, qualitative instruments are usually not checked for validity and reliability, which increases the risk of bias. This is partially due to the fact that qualitative studies allow for subjective collection and analysis of data in which the researcher is also a participant in the study (Katz-Buonincontro & Anderson, 2018; Rowley, 2014).

The use of a qualitative method would contradict the purpose of the project and affect the opportunity to use its results for practice improvement. Based on the information above, the chosen approach of a quantitative study proves to be more effective than its qualitative alternative at answering the selected clinical question. The central question posed for the project considers the participants’ level of knowledge and its connection to the use of capnography. By addressing the chosen question with quasi-experimental analysis, not only will the data provide the answers to address the gaps in the project’s design, but it will also address the questions into whether improvements in nursing knowledge in the use of capnography has any significance in influencing its use within the coronary care environment.

Nature of the Project Design

The quasi-experimental pre-test post-test analysis is selected as the primary design for this project. Pre-test post-test design is selected because it contains specific procedures that will be executed to align the project with its purpose and the identified clinical statements. The focus of the project is to assess the degree of capnography use in particular scenarios (CPR) by nurses, depending on their existing and acquired knowledge about the procedure. The clinical question introduces a connection between these two variables as well as the comparison between the outcome before and after the intervention, which leads one to propose their contest and correlation as the center of the project. Furthermore, the use of capnography is juxtaposed with the current practice, which further invites one to compare these variables and evaluate their interrelatedness with nursing education. This research design relies on quantitative data collection and analysis methods to examine the relationship between two or more variables (Ingham-Broomfield, 2014). The variables used in quasi-experimental research, such as nurses’ knowledge and the use of capnography, closely reflect the true experiences and perceptions of the participants in a study (Price, Jhangiani, Chiang, Leighton, & Cuttler, 2017).

The sample, according to the project’s questions, includes patients in the ICU of a hospital located in New Jersey. A sampling of the population in the project will require extracting of a subset from the general frame to be examined. It is vital for the participants to come from a unit where cardiopulmonary resuscitation (CPR) have occurred – the patients have to have experienced CPR in the unit. The sample size is based on the fact that the ICU usually has 20 licensed beds, but has been operating at an 8-10 bed capacity. There are 32 nurses working in the unit, which is necessary to know to prepare the educational program.

Structured questionnaires containing the selected survey instruments will be used for data collection in this project. First, some demographic data will be collected in order to create some features for grouping and the participants’ analysis, but no identifying data will be recorded for the project. Some data collection procedures that are necessary to address the clinical question include testing the nurse’s knowledge in the use of capnography in cardiopulmonary resuscitation procedures. These survey questions will be relevant to providing to answer the sub-questions framed in this project’s premise as well as its main purpose (Campbell, 2017; Kiekkas et al., 2016; Nelson, 2018).

Definition of Terms

This section provides a brief overview of the operational terms of the project:

• Capnograph. The instrument used to measure and display the amount of cardon dioxide in one’s breath (Kiekkas et al., 2016).
• Capnography. Capnography is a non-invasive technique to monitor the concentration of partial pressure of carbon dioxide (Kiekkas et al., 2016). It can aid the nurse in tracking the patient’s progress and support one’s decision-making during cardiopulmonary resuscitation.
• Cardiac arrest. This term is defined as “the cessation of cardiac mechanical activity confirmed by the absence of a detectable pulse, unresponsiveness, and apnea” (Tobi & Amadasun, 2015, p. 132). Cardiac arrest leads to the patient’s death if the appropriate care is not provided immediately, and this adverse outcome, as well as the tools aiding its solution, are the focus of the present project.
• Cardiopulmonary resuscitation (CPR). This term identifies the process of restoring the patient’s blood flow during a cardiac arrest using chest compression and artificial ventilation (Kodali & Urman, 2014). There are specific, detailed guidelines on how to perform cardiopulmonary resuscitation that provide the foundation on which the assessment of the nurses’ knowledge regarding this technique will be based in this project.
• Electronic Health Record (EHR). A digital version of a patient’s record that contains information about patients recorded and updated in real time (Lin et al., 2018). An EHR allows hospitals to collect, systematize, share, and use patient data for diagnosis and treatment.
• Pretest-posttest design. A type of quasi-experimental design, in which the dependent variable is measured before and after the independent variable is implemented (Valente & MacKinnon, 2017). This gap in examination allows one to see the impact of the intervention or treatment on the dependent variable.

Assumptions, Limitations, Delimitations

Assumptions. The following methodological assumptions were made as part of designing the project:

1. The information gathered from the participants will reflect the overall situation in an ICU of a 240-bed hospital in New Jersey. Although the sample is small, and there may be individual differences among the participants, it is assumed that their attitudes and perspectives will match those of nurses working within a similar setting under similar situations. It is likely that the hospital has similar standards, training, and equipment available for its medical staff.
2. The nurses selected for the project will have time to participate in the testing portion of the proposed clinical question. The chosen quantitative methodology implies that each participant will complete the NKCT (“Nurses’ Knowledge about Capnography Test”) chosen for testing nurses’ knowledge of capnography use (Kiekkas et al., 2016). This test will assess the nurses’ education and information retention on the subject and how they perceive the importance of this procedure within the clinical setting. Nurses have a busy schedule, but an expectation is that their participation in the project will help one to obtain the appropriate data and improve patient outcomes as a result.

Limitations. The project limitations are:

1. The lack of funding prolongs the data collection process. Providing compensation to nurses for taking part in testing would increase the response rate and nurses’ willingness to participate in the project.
2. The project’s question and methodology raise some ethical considerations. While conducting studies involving human subjects, scholars face many ethical challenges (Sanjari, Bahramnezhad, Fomani, Shoghi, & Cheraghi, 2014; Zyphur & Pierides, 2017). For example, it may not be possible to conduct observations or test participants as planned. Moreover, the issue of information privacy always exists in quantitative research where one’s results should not affect their career and organizational environment.

Delimitations. The proposed delimitations within this project are as follows:

1. Institutional support for recruiting and testing participants is necessary. This type of help could help to improve nurses’ willingness to participate in the project and remove the obstacles to conducting observations.
2. Contingency planning for ethical compliance in performing an analysis could help to identify potential ethical constraints and plan for using alternative tools or techniques if necessary.

Summary and Organization of the Remainder of the Project

Overall, cardiopulmonary resuscitation is an essential process in coronary care settings, and additional techniques could increase the chances of survival. As shown above, the rates of people suffering from cardiac arrest annually are high, while the rate of survivors is low (Edelson et al., 2014). Capnography proves to be a valuable addition to the standard CPR procedures in monitoring the patient’s condition and predicting adverse events (Hamrick et al., 2017; Heradstveit & Heltne, 2014; Kodali & Urman, 2014; Venkatesh & Keating, 2017). The examination of the available data reveals the need to explore the barriers to the consistent implementation of capnography use and its effects. Furthermore, the previous research also demonstrates the importance of examining the nurses’ knowledge and attitude toward capnography in CPR and their utilization of these concepts in practice. Some studies suggest that many nurses are hesitant to apply such techniques due to the lack of proper training and experience (Lin et al., 2017; Lin et al., 2015; Novais & Moreira, 2015; Pantazopoulos et al., 2015).

This topic has limited evidence in the works of literature and thus continues to create gaps in data on how nursing knowledge affects their readiness to use capnography while complying with standard procedures. The project aims to advance the knowledge in this area, and the insight gained could be useful for nurses in the improvement of patient outcomes and practice. This present DPI project will seek to address this problem by establishing the relationship between nurses’ knowledge, the use of capnography, and how they correlate into contributing to positive patient outcomes.

The literature review provided in Chapter Two will present an in-depth view of the barriers associated with capnography use as they relate to nurses’ knowledge through the examination of scholarly findings on the topic and its importance within the clinical setting. Chapter Three of the project will explore the selected quasi-experimental methodology for data collection and analysis. The data analysis will be documented in Chapter Four, which will also demonstrate the calculations of the study in visual form. Finally, Chapter 5 will provide a discussion of the project and consider its connection to the existing scholarship and practice environment.

Literature Review

Introduction

At the present time, capnography is applied as a monitoring tool in a variety of clinical settings, including the operating theater and intensive care units (ICUs). Its main purpose is to help nurses assess patients’ end-tidal carbon dioxide (ETCO2) levels (Conway et al., 2018). This information allows one to understand the efficiency of a person’s metabolic and respiratory functions while under medical care. Additionally, during cardiopulmonary resuscitation (CPR), capnography provides an evaluation of both the cardiac function and organ perfusion, allowing monitoring of the effect of CPR efforts and predictions regarding the restoration of spontaneous circulation (ROSC). The purpose of this quantitative project is to examine the application of capnography usage within the ICU setting during CPR and show how its application can impact patient outcomes and nursing practices when compared to current practice. Thus, the literature review’s main themes are concerned with the use of capnography, especially when performing CPR, nursing knowledge, and patient outcomes.

The present literature review considers the information from peer-reviewed journals, conference proceedings publications, and books gathered by the author, with the focus on research articles. Academic journals were the foundation of the project’s investigation, as their recent knowledge showed the current use of capnography as well as the aspects (weaknesses, strengths, and potential problems) of its introduction to the clinical sphere. The collected articles contained the analyses, debates, arguments, and discussions pertaining to contrasting and similar reviews relating to the use of capnography in a clinical setting.

After the introduction, the literature review offers a brief background into the use of capnography in clinical settings. This part shows the information on the procedures’ history, the evolution of the question posed in this project as well as potential gaps in the literature identified in the scholarship. Then, the review of the literature offers several sections and subsections in which the selected articles were divided. The topics (sections) discussed in this project include:

1. the use of capnography in different settings and relevant protocols;
2. the effect of various capnography measurement models on patient outcomes;
3. the impact of nurses’ knowledge on patient outcomes;
4. the connection between nurses’ knowledge and improvement of practice;
5. the correlation between CPR and capnography application;
6. the perception of capnography application during CPR.

These topics offer an academic, logical, and rational discussion of reviews on nurses’ use of capnography as part of clinical practice in relation to patient management during cardiopulmonary resuscitation. They include subsections that discuss alternatives to capnography, nurses’ attitudes to CPR and capnography, and the impact of change on nurses and patient outcomes.

The search for the appropriate studies included in this review involved the author’s ability to search using key words such as capnography, resuscitation, cardiopulmonary, resuscitation, innovation, clinical setting, cardiac. These key words were utilized when searching through several databases, including but not limited to Elsevier, NCBI, and PubMed, and ProQuest Central. Prior to being selected, all articles were appraised according to their relevance to the project’s topic, date of publication, clinical question(s), methodology, quality of evidence, and limitations acknowledged by the investigators. The online library offers capabilities that increase one’s access to recent studies from many institutions and research centers.

The understanding of capnography invention, its initial use, and current trends help enhance the knowledge of the implications of its application and the prospects for the future development of capnography. From a historical perspective, capnography is a relatively new approach to evaluating a patient’s health state. The introduction of capnography to the clinical setting in the United States occurred in 1978, and registered nurses began using this tool in recent years to aid patient care (Harper, 2005). However, capnography as an instrument was developed in the 20th century, indicating a long history of using capnography in medicine. Hence, one can see the early onset of the problem of the uses that capnography can have in medical care.

One of the main issues considered in literature is the use of capnography in emergency and nonemergency situations as well as different units of the hospital. Wright (2017) argues that although capnography has been used in the clinical setting for many years, the actual use of this approach was limited. Anesthesia procedures and the practice of using capnography instruments for monitoring cardiac attacks have gained attention in its application in the healthcare setting. Gravenstein, Jaffe, Gravenstein, and Paulus (2011) state that capnography can be used to measure CO2 levels, metabolism, circulation, and other useful metrics, providing an extensive assessment of a patient’s well-being that is useful not only in emergency care but also in day to day monitoring of patients. Therefore, capnography as a monitoring tool provides medical personnel with a better understanding of patient health state because the interpretation of waveforms can serve more purposes than that of the measurement of ETCO2. This DPI project hopes to share a light on this statement, strengthening the argument that capnography’s uses are wide in the ICU.

Theoretical Foundations

The theoretical foundation of the present project is Lewin’s change theory. Originally introduced by Kurt Lewin in the 1940s, the model is still used by businesses and other organizations to this day. It is an approach to change that is based on three main stages: unfreeze, change, and refreeze (Lewin, 1951). Each of these steps contains a list of specific actions that aim to lower participants’ resistance to change and increase its chance of becoming the new standard. The first stage, unfreezing, implies that the current order of operation has to be uprooted in order to introduce new objectives. Here, the change is to be viewed as necessary – the organizational beliefs can be challenged with evidence, information dissemination, planning, and refocusing (Morse, 2017). Next, the step of changing involves all processes that are needed to institute the new order in the place of the old status quo. Here, the evidence transforms into the project, and its elements are completed to create the new system. Finally, the refreezing stage ensures that people continue to embrace change and that any problems are addressed timely.

The seminal work by Lewin that describes these steps and outlines them in detail was published in 1951, after his passing. In it, the author introduces the stages and discusses the importance of them, showing how unfreezing and refreezing affect the attitude of involved persons towards change. Many contemporary researchers analyze the change model and show how it is still relevant to management. Burnes (2004) and Cummings, Bridgman, and Brown (2016) consider this model one of the most valuable business and management theories that were ever created. They note that Lewin’s change model has roots in both psychological and business ideologies, acknowledging people’s resistance to new information and change and devising approaches that address this barrier. Hussain et al. (2018) and Burnes and Bargal (2017) show that the simplistic formula of three steps can be questioned, but its role in innovation is valuable for all industries and spheres where employees play a significant role in the success of the system.

Lewin’s model of change was chosen as a theoretic foundation for this project due to the abundance of medical research using this approach and their results in its implementation. According to Udod and Wagner (2018), this approach is widely used in healthcare. Its use of steps and the view of employees as vital members of the process can help nurses to adjust to the new procedure. Capnography is the tool that is known among nurses, but its use can be limited due to the staff’s knowledge and perception (Kaminska, Wieczorek, Dabrowski, Nadolny, & Smereka, 2018). The clinical question posed in this research looks at how this barrier can impact patient outcomes and how new practice can lead to positive results. Thus, as change burdened by negative perceptions lies at the core of this project, Lewin’s change model appears to be the most suitable theory to achieve results.

Review of the Literature

The complications connected to varied airway events often occur outside the operating theater and result in high mortality rates. Kerslake and Kelly (2016) state that in around 70% of explored cases application of capnography would help mitigate the adverse impact of airway complications or prevent deaths of patients. These statistics are valid for patients dependent on artificial airway support. In addition, capnography application in ICU units can provide valuable input in monitoring ETCO2 levels during resuscitation. The following subsections will examine the evidence suggesting the necessity of utilizing capnography during CPR and the current evidence relating to nurses’ knowledge of this instrument as well as data relating to its application.

Capnography and alternatives in resuscitation. In the United States, the American Heart Association advises on using capnography during CPR (“2015 international guidelines on CPR,” 2015). In Europe, the NAP4 guidelines, which are published for medical institutions both in Europe and the United Kingdom, use of capnography is obligatory for patients subjected to anesthesia, regardless of the devices used for airway support (Kerslake & Kelly, 2016; Soar et al., 2015; Link et al., 2015). Additionally, patients receiving advanced life support should also receive continuous capnography monitoring to detect any life-threatening changes. While this suggests that capnography can be helpful in preventing mortality or airway complications in patients within varied clinical settings, the use of capnography during resuscitation procedures is the topic that requires additional exploration.

The history of capnography in resuscitation. Capnography, as an instrument, has been applied in medical settings for over forty years. At first, it was applied for patients under anesthesia – to monitor their coronary condition in the sedated state (Kalenda, 1978). In Holland, it became a standard of safety in the middle of the 20^th century. Nevertheless, the use of capnography during CPR remained under question, and it continues to be a center of debate in the medical field. As the present studies show, the evidence that supports the use of capnography during CPR has been published since 1978, and some of the most recent articles show similar findings in 2018.

The first use of capnography during resuscitation. The first article describing the application of this monitoring tool in a clinical setting, more specifically during resuscitation, was published by Kalenda (1978). In it, the author suggests that monitoring pulmonary perfusion during cardiac massage performed for patient resuscitation can enhance the outcomes. The patient cases presented by Kalenda (1978) suggest that changing resuscitating strategies reduces patient mortality rates. This article shows that the presence of a capnography tool allows nurses to control the process more accurately and adjust the cardiac massage as necessary, affecting the efficiency of the resuscitation efforts.

Capnography as a source of data for CPR. Similar to the evidence presented by Kalenda (1978), more recent literature such as the article by Hartmann et al. (2015), suggests that applying capnography during resuscitation helps decrease mortality rates. Hartmann et al. (2015) present a systematic review and meta-analysis of the evidence showing what role ETCO2 measurements play in CPR. Their review considers 27 studies and finds that the transparency offered by capnography allows nurses to see the threshold for ETCO2 goals during resuscitation. This analysis reveals the important place of capnography in supporting the success of CPR and patient outcomes.

Capnogram-based ventilation detection in CPR. The article by Gutiérrez et al. (2018) explores how capnography use during CPR can be enhanced to report more reliable data. In this text, one can see that the positive impact of capnography is undisputed. The authors collect cardiac arrest defibrillator recordings with capnograms and compare the performance of algorithms with and without a filter for capnography. They find a way to make capnography show more accurate data to increase positive patient outcomes, further arguing that capnography is a valuable tool for the procedure of resuscitation. It should be noted that other studies such as the one by Lampe (2017) also advocate for improving the process of monitoring ventilation using capnography.

Alternatives to capnography and their limitations. Capnography is not the only method for evaluating these vital signs, but it is more efficient when compared to others, which impacts the quality of care and is especially crucial during CPR, where timing and efficiency of actions can affect the likelihood of survival. According to Gravenstein et al. (2011), capnography is “the continuous recording of CO2 partial pressure [pp] in inspiratory and expiratory gases” (p. 418). A similar method titled capnometry exists; however, it does not provide an opportunity to monitor a patient’s CO2 levels, instead of giving a numerical assessment at a given point in time.

Old and new studies review the use of this tool during resuscitation efforts, consistently finding that the information capnography provides to nurses is invaluable to their knowledge about the patient’s coronary health as well as their chances for success. Thus, research from the last five decades shows that capnography should be an integral part of the ICU setting (Gutiérrez et al., 2018; Hartmann et al., 2015; Kalenda, 1978). The history of capnography reviewed with the help of these articles support the place of capnography in the ICU and situations outside of the usual use during anesthesia.

Different uses of capnography. The history of capnography shows that this tool has been widely used in a variety of medical spheres. It is essential for many areas outside of resuscitation, and its first creation did not intend for this instrument to be utilized in the way the present topic considers. Nonetheless, with time, capnography also gained recognition in several sphere, including emergency situations and resuscitation.

Capnography outside of resuscitation. Examining the scholarly articles on the topic of capnography for other emergencies and non-emergency situations in the hospital setting can help evaluate the current best practices using evidence-based suggestions and understand the methodology and specifics of the chosen approach. While the discussed literature analyzes the utilization of capnography in various settings, further research can help improve the application of this tool in a clinical setting during CPR. The following articles demonstrate the broad scope of areas to which capnography is a valuable addition.

Capnography and anesthesia. In general, capnography is helpful in the operating theatre during anesthesia; this non-operative practice allows the monitoring of patients. According to Pantazopulus et al. (2015), “low ETCO2 levels may indicate hyperventilation, apnea, esophageal intubation, occlusion of the endotracheal tube, leakage in the ventilation system, poor systemic and pulmonary circulation, hypothermia, massive pulmonary embolism, or ineffective chest compressions” (p. 1053). The systematic literature review conducted by the authors outlines two main themes connected to the application of this tool exist – implementation and interpretation of results. The latter is especially relevant for the issue of resuscitation because a nurse or other medical professional has to be capable to quickly assess and interpret the results of monitoring to adjust resuscitation or change the inhalation tubes for patients. The use of capnography in ICU resuscitation can improve the number of successful patient cases. However, filtering practices allowing medical personnel to receive reliable results from capnography tools must be implemented since fast oscillations connected to chest compressions can obstruct the resuscitation.

Opioid-induced respiratory issues and capnography. A study by Stites, Surprise, McNiel, Northrop, and De Ruyter (2017) revealed that capnography could reduce the number of opioid-induced respiratory issues. The clinical setting observed by the authors implemented the utilization of capnography, and the outcomes suggest a statistically significant improvement in the PCA efforts. The methodology used by the authors of the explored studies suggests that short-term cohort research is the best practice for approaching the issue. Most researchers explored evidence by examining patient records, implying that retrospective studies are conventional approaches to discussing this topic.

Respiratory depression and capnography. Langham, Li, and Lichtor (2016) consider capnography outside of anesthesia and suggest that children should be monitored using this tool to detect hypoventilation and apnea, which is also supported by Subramani et al. (2017). In this case, the cross-sectional study demonstrates the broad application of capnography and its ability to monitor patients whose health is not directly related to anesthesia. The authors find that routine monitoring can improve patient health, thus showing that capnography has many uses, including those in the ICU.

Capnography and metabolic changes. Cereceda-Sánchez and Molina-Mula (2017) reviewed the prospects of using capnography in the ED setting for detecting metabolic changes in patients. Since the article is a systemic literature review, the methodology that the authors used involved an examination of 17 studies focusing on the specifics of capnography. The findings suggest that this tool is efficient and cost-effective, which further promotes the need to develop and implement strategies promoting the use of it in the hospital setting.

Capnography allows monitoring the concentration of the carbon dioxide (CO2) in the respiratory gases of the patient. In medicine, this tool is currently used during anesthesia or in intensive care units, while some new studies suggest that using capnography ICU can improve patient outcomes. Capnography allows the medical personnel to monitor the inhaled and exhaled gases. Another benefit of this approach is that it presents an indirect assessment of the patient’s partial pressure in the arterial blood. The importance of using capnography not only in the operating theatre but also in resuscitation or other emergencies is connected to its ability to detect airways complications in patients.

Capnography and resuscitation. The general theme of the literature is that capnography has a statistically significant impact on patient outcomes in many areas, including during CPR. The present studies show why capnography is invaluable during resuscitation. Some of them also introduce this tool to improve the outcomes of CPR and lower the risks related to it. A specific practice problem is the impact of nurses’ knowledge on the practice of using capnography in ICU during CPR. Hence, the topic of this paper is practice improvement that will help nurses use capnography tools and interpret results for adjusting resuscitating efforts in the ICU.

Capnography in critical care. While capnography is not the only approach to measuring CO2 levels in a clinical setting, it is the most efficient and accurate. It improves the nurse’s ability to diagnose respiratory issues and mitigate them, which is especially crucial during CPR. The main principle of capnography tools’ work is the evaluation of CO2 levels, which is useful in determining the production of CO2, lung perfusion, patient’s respiratory patterns, and alveolar ventilation. The capnometer measures the CO2 concentrations using a gas sample collected from a patient (Kerslake & Kelly, 2016). Capnography trace or waveform is the graphic representation of results with time and partial CO2 pressure displayed on X and Y-axes. Hence, the authors conclude that the continuous monitoring that this instrument provides is vital in the context of the CPR set.

Capnography for death prevention. Cook and Garrop-Griffinth (2019) argue that the utilization of capnography in the varied clinical setting can serve as a measure for preventing deaths. The authors base their conclusions on a study of contemporary practices applied in hospitals. The results suggest that a large percentage of individuals are dying due to misplaced tubes or esophageal intubation, which can be prevented by using capnography. The common reasons cited by the authors are the failure to use capnography and the lack of education about this tool that would allow medical personnel to use it in case of emergencies.

Capnography and out-of-hospital cardiac arrest. Lui et al. (2016) consider the value of accumulating data about ETCO2 during patient resuscitation in out-of-hospital cardiac arrest cases. The authors perform a cross-sectional study of adults and find that the information that capnography provides can diagnose cardiac arrest and help nurses to determine the patient’s state. Their findings align with those of Elola et al. (2019), Sheak et al. (2015) and Gong, Lu, Zhang, Zhang, and Li (2015). This study shows how one’s knowledge of circulation can help with CPR and notes that capnography is essential in such procedures, further strengthening the place of this tool in resuscitation efforts.

Capnography for reducing chest compression. Capnography can be used to reduce chest compressions when resuscitating patients. This methodology was developed by Leturiondo et al. (2019) and Merckx, Lambert, Cantineau, and Duvaidestin (1992) and incorporated capnography-based chest monitoring tailored for the purposes of cardiopulmonary resuscitation. The issue with the approach currently used in medical establishments is that chest compressions affect the accuracy of automated ventilation detection, which can endanger the patient. Leturiondo et al. (2018) developed an algorithm that considers this issue and allows detecting insufficiencies in patient ventilation. Hence, the accuracy of results and reliability of capnography affects the outcomes of resuscitation efforts (Ruiz de Gauna et al., 2018). This methodology suggests that while applying capnography during resuscitation helps improve the patient state, more developments, and evidence-based research is required to develop practice improvements.

Potential barriers to using capnography in CPR. Capnography has solidified itself as a preventative measure in accessing CO2 levels, but its use within these types for CPR should be researched further. De Caen and Maconochie (2018) argue that “recent systematic reviews suggest, however, that using specific EtCO2 values to guide patient care during adult cardiac arrest is based upon low-quality evidence” (p. 2). Hence, the lack of high-quality literature and reliable data regarding cut-offs and respiratory patterns measured with capnography can explain why the perception of this technique and its use by nurses during CPR is insufficient. Regarding outcome predictions, several studies suggest that capnography can be applied when determining the patient’s state upon CPR.

Current application of capnography. It is also necessary to understand that nurses in different departments can use capnography, and the decision-making process should incorporate a variety of patient-related factors. Bullock, Dodington, Donoghue, and Langhan (2017) examine patient cases of resuscitation in a pediatric department to identify whether the guidelines by the American Heart Association (AHA) in 2010 are applicable and the specifics of utilizing capnography depending on patient characteristics. The research methodology involved a retrospective review of charts assessing data such as trauma, sex, age, capnography results, and patient outcomes. The conclusions suggest that the use of capnography in CPR procedures is inadequate since it was applied in only 13% of cases (Bullock et al., 2017). Moreover, the case reports indicate that individuals who had CPR with capnography were more prone to have a spontaneous circulation in comparison to patients not receiving it. The overall duration of CPR procedures was longer in cases with applied capnography, suggesting that this instrument improves the accuracy of patient prognosis. This study contributes to the posed clinical question as it highlights the benefits of capnography and the lack of its proper application in hospitals.

As a result, the present studies show how capnography can prevent avoidable deaths due to unsuccessful resuscitation. According to Cook and Garrop-Griffin (2019), “expired carbon dioxide is routinely detectable during the management of patients with recent cardiac arrest, even in the absence of chest compressions” (p. 439). This evidence provides support for the use of capnography in the ICU. It also raises the question of why this topic is still the subject of debate and presents some inquiries into nurses’ perception of capnography as a valuable instrument during CPR.

Nursing knowledge and patient outcomes. Education of medical personnel regarding capnography use and the interpretation of results has an impact on the use of this tool. While capnography has been used in a clinical setting for almost fifty years, some literature findings suggest the need to dedicate more attention towards educating medical personnel to use this method appropriately for monitoring a patient’s health state and detecting possible heart failure (Langham, Li, & Lichtor, 2017; Long, Koyfman, & Vivirito, 2017). This is a vital component that helps ensure that medical professionals can interpret the capnography traces adequately (Kerslake & Kelly, 2016). Another aspect is the attitudes and perception of nurses that may view capnography as an unnecessary tool that impedes rather than assists their performance.

Nurses’ knowledge about capnography and other procedures. Nurses and factors relating to their work have a direct impact on patient outcomes, and improvement of practice approaches or hospital environment can enhance health-related metrics in patients. This idea suggests that a variety of factors, including the availability of capnography tools, is hospitals, skills that allow nurses to use and interpret waveforms, personnel perceptions of the technique, and the overall attitude of a healthcare organization can affect the practice of using capnography in the ICU (Jaffe, 2017; Darocha et al., 2017). The methodology used in studies by Gong et al. (2015), Chhajed, et al. (2017), Darocha et al. (2017), is a mixed design, incorporating a qualitative assessment of nurses’ opinions, hospital managers perception of capnography, and quantitative analysis of patient data. The literature findings relating to these issues allow designing a questionnaire that will account for all aspects that obstruct or facilitate the utilization of capnography by nurses, making this DPI more comprehensive.

Nursing knowledge and patient survival outcomes. Assessment of death associated with failure to apply tools such as capnography can provide an insight into the severer of the problem. Pantazopoulos et al. (2015) argue that only 20% of patients that receive resuscitation survive, despite the recent advancements in the techniques and technology application used to monitor the process and improve the outcomes. Moreover, in the setting outside the hospital, the statistics suggest a survival rate of only 10% (Pantazopoulos et al., 2015). Hence, determining the issues that contribute to the high mortality and possible best practices to help reduce the number of adverse incidents can help design guidelines for medical practitioners. One aspect is the application of capnography, which provides continuous monitoring of the patient’s respiratory system and helps to prevent or reduce the risk of emergency situations.

Nursing training and capnography. The ability to apply capnography is also affected by the technical expertise that enables using innovational instruments and tools, and it is essential to ensure that nurses possess sufficient knowledge to implement capnography in the critical care unit. Wright (2017) notes that “with overwhelming lack of proper training related to new technology devices such capnography, a sound developmental training program regarding the use of capnography can positively affect patient safety and outcomes” (p. 10). The author shows that training is an essential aspect in developing improvement practice suggestions since the ability to use the capnography is crucial for adequate measurement of CO2 levels and adjustment of resuscitation strategies in accordance with this assessment.

Training and quality of work using capnography. Saunders, Struya, Pollock, Mestek, and Lightdale (2017) focus on the correlation between education or training and the quality of work displayed by nurses when they use capnography in a hospital setting. Although they do not use this tool during resuscitation in the study’s case, nurses’ training with the instrument impacts their ability to help patients and lower the need for assisted ventilation, according to the findings of the study (Saunders et al., 2017). Thus, one can see how such an aspect as training has clinical value and can impact patient outcomes, and it is suggested to develop and implement education programs that target this problem in CPR.

Implications of capnography in medicine. According to Aramendi et al. (2017), “capnography permits monitoring ventilation, but the chest compressions provided during CPR corrupt the capnogram and compromised the accuracy of automatic ventilation detectors” (p. 41). The authors explored 83 episodes of cardiac arrest both in the hospital setting and outside the clinical setting, to determine the best practices for using capnography in resuscitation. The findings suggest that an approach using only a capnography tool can be a valid strategy in the resuscitation process. The explored evidence suggests that practice improvement guidelines should incorporate strategies for educating and training medical personnel to use capnography in emergencies, for instance, when resuscitating a patient in an ICU unit.

Supplemental training to facilitate capnography use. As was previously mentioned, some researchers point out that the use of capnography, as a part of CPR, requires additional attention because the waveform can be distorted by chest compressions, indicating a need for additional training required for nurses working in ICUs. Leturiondo et al. (2018) state that over 70% of waveforms examined in their study was distorted because of resuscitation efforts. This requires the development of an algorithm specially tailored towards CPR that would mitigate the impact of chest compressions on capnography results, minimizing the distortion. The focus of capnography application during resuscitation efforts is on determining whether the endotracheal tube was placed correctly, ensuring that the performed chest compressions are done correctly, and detecting ROSC. Additionally, Leturiondo et al. (2018) argue that capnography can be utilized to develop a prognosis for patients. Ventilation rate monitoring is essential during CPR because it helps nurses detect hyperventilation and prevent adverse patient events.

Distortion of the breathing patterns. In this study, Ristagno et al. (2015) inspect data from 1617 patients with ventricular fibrillation and find that, in general, visual inspection of the waveform is enough for tracking breathing patterns of individuals. The reliability of results produced through capnography during CRP can be questioned because of distortion, and it is necessary to conduct further research. This article presents some potential risks of using capnography without sufficient training, explaining the potential hesitation of nurses towards this change project, and laying some ground for the first step of the intervention.

This theme was explored because the goal of this DPI project is to explore the relationships between nurses’ knowledge about capnography and its application to the number of adverse outcomes in the ICU. Therefore, the relationship between factors that impact a nurse’s work and professional qualities such as education or skills should be explored to determine the significance of this aspect. While alternative approaches to the issue may suggest that quality of care is facilitated only by the specifics of nurse training, it is evident that other factors contribute to this aspect as well.

Specific protocols for using capnography. Although capnography as an instrument is not difficult to apply in a clinical setting because it is non-invasive and requires only the presence of capnography and a medical professional capable of interpreting the results, there a variety of algorithms and strategies for using this instrument which complicates nursing training. Guidelines for using capnography can influence the ways nurses use this tool, and the following articles explore this connection.

Resuscitation-specific capnography utilization. Capnography is a valuable tool that allows for enhancing the process of monitoring a patient’s respiratory function in an emergency scenario, making it relevant during resuscitation attempts. Examination of the capnography in the emergency department helps outline the basis for interview topics that will be applied for this project. While many studies considered above review the place of capnography in the process of resuscitation, and some guidelines recommend this tool, scholars continue to explore the aspects of this procedure and its application in the ICU.

Guidelines for the application of capnography. Haines (2017) examined guidelines and practices used in emergency departments (ED) to provide a qualitative assessment of the capnography application and its benefits. Patients in the EDs are at high risk of developing complications because of respiratory function impairment. Thus, the information from this study helps improve the DPI by providing explanations of the application and possible reasoning that explains why this instrument is underused in the United States hospitals. Haines’ (2017) findings are complicit with those of other authors arguing that capnography is beneficial during CPR since it allows the medical personnel to provide continuous chest compressions without a need to check the patient’s pulse.

Different outcomes of capnography. Research shows that capnography is more efficient when compared to other respiratory monitoring techniques. For instance, pulse oximetry can be used to detect hypoxia, but the results are not produced continuously (Haines, 2017). Capnography is a non-invasive technique that does not require additional preparations for use, but one should consider different instruments and their appropriateness within the ICU setting. Moreover, the authors considers the variety of method for capnography use.

Two main models of capnography. According to Kellshake and Kelly (2016), currently, two models of applying capnography tools and measuring the CO2 levels exist. The first one is a side stream analyzer, which implies taking a sample of gas from the patient’s respiratory tube and placing it in the humidifier filter. This approach is applied in a setting for non-intubated patients because it is more comfortable, and the equipment required for analysis is less bulky when compared to the other two methods. Mainstream analyzers use infrared light that scans the ventilation circuit. This method is more suitable for monitoring patients during resuscitation.

Combining capnography and other tools. Some researchers explored the different combinations of tools and techniques to develop the best practice of applying capnography, which can be used in practice improvement. Salen et al. (2001) explored the possibility of combining capnography tools with a cardiac sonographer in order to improve the procedure of patient resuscitation. The objective was to measure the accuracy of predicting resuscitation outcomes using the two instruments in the emergency department (ED). The combination did not provide significant improvements, but capnography was shown to be a major predictor of survival (Salen et al., 2001). Thus, its use in resuscitation is supported further by this research.

Overall, there exists an abundance of research that shows how capnography helps during resuscitation. However, many studies also note the difficulties related to this procedure – while it is non-invasive, it requires sufficient experience and knowledge from nurses to produce successful outcomes. From this idea, another subtheme emerges – the necessity of education for nurses to improve the use of capnography in the ICU, namely during resuscitation.

Education to widen capnography use. The focus of this practice improvement project is on intensive care units and resuscitation, but the overview of history suggests that capnography is applied in other hospital units, that have established standard guidelines for using capnography in a clinical setting. In general, capnography is usually utilized during anesthesia to monitor a patient’s respiratory function. Only in recent years, researches and practitioners began exploring the implications and benefits of using this monitoring tool in other hospital units, as shown above. This contributes to the understanding of the specific information that this DPI should investigate.

Patient selection for capnography. First of all, there exists a conversation about which patients can be subjected to capnography. Kerslake and Kelly (2016) state that “capnography can be used both for intubated and non-intubated patients” (p. 178). The diversity of metrics that can be assessed using capnography presents an understanding of the need to dedicate special attention to educating medical personnel about how and when to use capnography and how to interpret the results. According to Kershake and Kelly (2016), capnography “can be used to detect displaced tracheal tubes and tracheostomy tubes and to diagnose inadvertent esophageal intubation” (p. 178). Additionally, the authors argue that this method can be applied to monitor the cardiovascular functions of a human’s body.

Automated monitoring to overcome chest compression. Turle, Sherren, Nicholson, Callaghan, and Shepherd (2015) suggest applying automated respiratory monitoring with specific algorithms that help disregard the impact of chest compressions of capnography results. Their methodology, questionnaires and telephone conversations, informs the approach chosen for this DPI. Out of 211 establishments, only four did not have the equipment necessary to conduct capnography assessment, and only 50% of respondents stated that capnography was used to measure the efficiency of CPR (Turle et al., 2015). These findings indicate the inefficiency of use connected to capnography utilization in the United Kingdom hospitals. In addition, this study suggests that most establishments lacked the necessary equipment to perform the measurement in general wards. Arguably, the application of such a strategy would require an even more in-depth knowledge of technology from nurses who would use this instrument in their practice during CPRs.

Reading capnography results. Nurses’ ability to accurately identify patterns and interpret waveform results can help in preventing adverse respiratory events. Pantazopoulos et al. (2015) state that “airway management, compression depth and chest recoil, hands-off time, and early defibrillation” are the critical measurements that capnography helps assess (p. 1053). Airway management is the primary emphasis of this study since it can be used to adjust other elements of resuscitation efforts. However, Pantazopoulos et al. (2015) suggest that current guidelines on monitoring the CO2 levels in a patient gas sample lack clarity and require further examination to develop best practices. Monitoring end-tidal CO2 is used, which involves evaluating the pressure upon exhale. Hence, the importance of the topic discussed in this project is highlighted by this research because explored evidence suggests that a large number of healthcare professionals lack an understanding of how capnography can improve patient care during resuscitation and affect mortality rates.

Nurses’ use of capnography readings. Zito, Berardinelli, Butler, Morrison, and Albert (2019) focused their attention on how nurses use capnography results to make decisions regarding patient discharges, using confidence levels assessment. This cross-sectional study observed 133 patients before and after ETCO2 assessments and measured nurses’ perception of the patient’s readiness for discharge. In the study, it is evident that nurses change their prognosis based on the outcomes of ETCO2 levels assessment. As was previously mentioned, despite the fact that capnography is mainly applied in the operating theater, most cases of airway complications occur outside this setting. Hence, there exists a need to evaluate the number of such cases and the readiness of nurses to apply capnography in the ICU unit.

Nurses’ Knowledge about Capnography Test (NKCT). An essential aspect of this project is the ability to accurately assess and measure nurses’ knowledge of capnography use in the CUU setting to be able to compare the two variables. Kiekkas et al. (2016) developed a questionnaire that allows accomplishing this goal titled Nurses’ Knowledge about Capnography Test (NKCT). The questions incorporated in this assessment aim to evaluate the understanding of capnography functions, aspects of end-tidal CO2 levels, waveform interpretation, and specifics of using capnography in a clinical setting.

This paper focuses explicitly on emergencies and the prospects of using capnography to improve patient outcomes. The literature suggests that capnography can significantly improve the current practices of resuscitation and CPR. According to the European Resuscitation Council, capnography use enables the detection of ROSC “without pausing continuous chest compressions thereby improving quality of resuscitation and preventing the potential harm caused by administering a further bolus of adrenaline after ROSC” (as cited in Kerslake & Kelly, 2017, p. 180). Therefore, nurses must possess the knowledge regarding capnography in resuscitation and the ability to recognize vital signs associated with ROSC.

Barriers to using capnography during resuscitation. As noted above, the complexity of using capnography outside of its usual setting is based not only on the tool itself or its availability in the hospital, but also nurses’ hesitance in following new evidence and recommendations. While American and international guidelines mention capnography as a valuable addition to the process of resuscitation, the number of cases where it is used remains low (Aramendi et al., 2017). Therefore, one has to look at possible barriers to capnography use outside of resource unavailability and the lack of value.

Improper waveform interpretation. According to Aramendi et al. (2018), capnography use is challenging as not all nurses can see the exact differences between breaths and chest compressions. The researchers were able to develop algorithms that allow medical personnel to use programs in a more advanced way, more specifically, for determining the location of ventilation. This study has several implications for the project; it implies the need to improve their current knowledge by providing them with the described algorithm. This can help enhance nurses’ confidence in using the technique as well. Additionally, this improves the CRP process in general by mitigating risks of hyperventilation, which is often associated with adverse patient outcomes.

Low adherence to clinical guidelines. Nassar and Kerber (2017) argue that despite the significant prevalence of poor outcomes associated with CPR and a large volume of evidence-based research providing guidelines regarding best practices within this domain, the adherence to these suggestions in clinical settings remains low. Nassar and Kerber (2017) state that “feedback devices provide instantaneous guidance to the rescuer, improve rescuer technique, and could impact patient outcomes” (p. 1061). The authors use a systematic review and list several elements that contribute to the improvement of CPR practices. They state that capnography is a critical aspect in monitoring chest compression and tracking the return of spontaneous circulation. This suggestion supports the primary claim of this DPI and highlights the need to determine what factors impact the lack of capnography application during CPR and develop interventions that can address these problems.

Perception of capnography application during CPR. The previous study suggests that the prevalence of capnography use among nurses use during CPR remains low. However, it is possible that other factors, apart from knowledge and perception, obstruct the adoption of this respiration-monitoring tool. Sahyoun, Siliciano, and Kessler (2018) developed a questionnaire for hospital managers to examine whether the hospitals in New York had equipment that would allow them to use capnography during resuscitation. Sahyoun et al. (2018) state that 95% of the respondents had the devices that allow their personnel monitoring ETCO2, and 97% implemented a protocol for applying them. However, only 54% reported having a protocol tailored explicitly for CPR, which is consistent with the findings of studies by Dioso (2017) and other studies mentioned in this review. Thus, despite the availability of capnography, hospital personnel may have difficulty applying these tools because no protocol or guideline that would help them is in place.

The absence of a protocol. One can argue that the lack of guidelines and efforts dedicated to ensuring that hospitals use capnography harms patients when those efforts are not consistent. Carlisle (2015) aimed to develop a standardized protocol for using capnography during resuscitation for opioid-induced respiratory depression (OIRD). This article explicitly targets nurses and their ability to use the tool during CPR. The author also notes the absence of education as a problem for nurses’ resistance to using the guidelines.

The lack of education. Hassankhani, Aghdam, Rahmani, and Mohammadpoorfard (2015) cites education as a vital factor for promoting the utilization of capnography in a clinical setting. The findings are based on the nurse interviews regarding the application of the protocol, and the answers suggest that issues are connected not only to the availability of devices and to the system issues and the lack of patient adherence.

The need for additional training. Whitaker and Benson (2016) indicate that approximately 74% of deaths in intensive care units (ICU) can be prevented if capnography monitoring is implemented as standard practice. The primary goal of this strategy is to improve patient safety; hence, the authors also recommend using a standardized protocol and providing nurses with additional training that would fill the gaps in knowledge and understanding of the interpretation of capnography.

In-depth knowledge of waveforms and distortions. Kodali and Urman (2014) suggest that universal application this tool during CPR will allow creating a database of waveforms that can be utilized to improve the existing protocols. Hence, the promotion of using this methodology will help further enhance the practice. Kodali and Urman (2014) conducted a literature search to locate evidence supporting the benefits of capnography in resuscitation published from 1960 and concluded that historically the interpretation of outcomes and attitudes regarding the predictions and evaluating that can be made using this approach changed since it is accepted that the “presence of small obtunded CO2 waveforms during CPR reinforces tracheal location of an endotracheal tube” (p. 332). In general, capnography use during resuscitation requires the knowledge of not only waveform interpretation, but also the understanding of distortions caused by CPR. The complexity of using capnography during resuscitation can be a curial factor contributing to nurses’ lack of confidence when using capnography, especially in emergency cases.

To summarize, this theme in academic research demonstrates several barriers that nurses encounter when using capnography during CPR. The most important one is the lack of training, which results in other problems arising when the hospital or unit wants to implement changes. Moreover, the lack of standardized data further increases nurses’ resistance to change, which offers some insight into the basis for the current project.

Summary

Overall, the problem that this project explores is the practice of using capnography in the ICU setting during patient resuscitation and the impact of nurses’ knowledge about the tool on the prevalence of use and CPR outcomes. The origin of the issue is connected to evidence presented by scholars, suggesting that nurses both in the United States and in Europe do not apply capnography to guide cardiac massage and track respiratory patterns of patients, despite the availability of capnography tools (Wright, 2017). This project aims to improve the lack of understanding associated with the perception and knowledge of capnography utilization and patient outcomes. Works similar to the study by Sahyoun, Siliciano, and Kessler (2018) aim to examine the problem of knowledge about capnography, perception, and the frequency of application. However, the sample size is little, suggesting that more attention should be dedicated to the problem of correlation between knowledge and application. The current literature lacks a study that would focus on this factor and use qualitative design.

The empirical evidence on the topic of capnography suggests that in most cases, using capnography during CPR improves the accuracy of cardiac massage and survival chances. The problem has evolved historically since initially capnography was developed as an instrument applied during anesthesia, but current trends suggest that it can make the care better across many domains (Jooste et al., 2019). However, the ability to use capnography is obstructed by the lack of knowledge and training. Capnography allows medical professionals to monitor a patient’s well-being in the ICUsand nurses in these units should receive not only protocols or guidelines but also adequate training on capnography.

In general, the application of capnography across different domains of patient care becomes more popular. The main trends in applying capnography for patient monitoring within the ICU settings are connected to the promotion of using this tool and improvement of result interpretation that can be obstructed by distortions (Aramendi et al., 2017; Chicote et al., 2019). The primary trend that prevails in the literature is the adoption of capnography for use in a different medical setting, including the ICU. The expansion of the use scope for this instrument suggests that many hospitals will want to have capnography available at each ward, further emphasizing the need to examine personnel’s ability to use this tool correctly (Kerslake & Kelly, 2016). In addition, many researchers develop specific algorithms, including computer programs that help enhance the result interpretation or automate the process of monitoring using capnography (Chicote et al., 2019). One can argue that the general trend is the application of capnography across different units and the improvement of application strategies.

Many studies are based on a small research sample of 20-30 nurses or patients, which can mean underrepresentation. The authors generalize the findings to create a conclusion based on the evidence they collect (Kerslake & Kelly, 2019; Jooste et al., 2019). From this perspective, one can argue that the evidence supporting the efficiency of using capnography in the ICU during resuscitation is not justified. However, other studies focus on exploring patient records to determine the effect of resuscitation using capnography on mortality, which can incorporate enough samples. Conflicts in methodology are connected to the prevalence of quantitative studies that assess the availability of capnography tools, the number of cases where it was applied, and outcomes.

Hence, a significant gap in the literature is the lack of evidence that would provide an understanding of nurses’ knowledge of capnography and attitudes towards using this tool. Prior research is done on the topic that explores the chosen phenomena is assessing the prevalence and specifics of nurses using capnography and suggests that in most cases, this instrument is not applied during CPR. Hence, the phenomena explored in this project are nurses’ knowledge, capnography use during CPR, and patient mortality, and the connection between these factors. The majority of the examined studies focus on the advances of using capnography and the specifics of its application (Kerslake & Kelly, 2016). Additionally, it can be argued that a gap in understanding the nurses’ knowledge and its impact on the perception of a tool exists, suggesting that projects such as this DPI can enhance the procedures at hospitals.

The methodologies and design used to explore the topic of capnography for resuscitation range from qualitative discussions to quantitative surveys, both of which can assess nurses’ knowledge regarding the use of capnography. The literature relates to the DPI since it explores the issue of resuscitation and the benefits of using capnography when measuring CO2 levels. While evidence suggests that using capnography, during resuscitation helps decrease mortality rates, some medical professionals do not use this tool and the ability to identify what factors influence this choice can help design interventions and practice improvement strategies that target the problem (Wright, 2017; de Caen & Maconochie, 2018). Since this DPI project is quantitative, the studies were chosen for the literature review that explored the data surrounding capnography as well as some barriers for nurses that the project could acknowledge when planning for change. In this way, the practices and best approaches for using capnography were located that allowed one to understand the specifics of this tool. Besides, the literature review allows comparing and contrasting different methods and the evolution of using capnography in CPR.

The reason for choosing Lewin and his change model as the foundation for this project lies in the gaps identified in the literature review. It is apparent that the equipment for capnography is present in most hospitals, and sufficient data exists to support the use of this tool during resuscitation. Nevertheless, the rates of using this instrument remain low, and nurses express hesitations surrounding this topic. Thus, a change theory that acknowledges people’s fear of change and resistance to new systems is necessary. Lewin’s model offers a simple theoretical base that shows how these obstacles can be overcome.

The quantitative, quasi-experimental methodology with an application of surveys was chosen to connect patient outcomes and nurses’ use of capnography in a calculable and transparent way. The main goal is to determine the degree to which capnography use during resuscitation impacts patient outcomes and nurses’ subsequent implementation of this tool in the unit. The appropriateness of the DPI’s strategies recommended by the similarities of design in the examined studies since the ones relating to the use of capnography in a clinical setting employed questionnaires and knowledge tests, as well as data such as mortality rates, similar to the model chosen for this DPI. Chapter 3 will focus on exploring the clinical question and on the methodology used for this DPI, using findings from the literature.

Methodology

This DPI project focuses on the use of capnography during CPR by nurses, linking their knowledge of capnography techniques and the application of capnography within an intensive care unit (ICU). To validate the arguments set forth, a quantitative method was chosen to explore the relationship between nursing knowledge of the utilization of capnography and how its usage was pertinent in positive outcome generation with the intensive care units (ICU). The questions guiding this project are whether nurses’ knowledge of capnography impacts the frequency of using this tool during resuscitation and whether nurses’ knowledge of capnography influences their compliance with capnography guidelines and procedures. Improving nursing knowledge in capnography is essential in increasing the quality of care and resuscitation efforts in generating positive outcomes for patient success rates and promoting increased patient outcomes. This chapter of the DPI project explores the methodology to be used in greater depth, including sampling procedures, data collection instruments, and data analysis methods in the evaluation of the premise.

Statement of the Problem

The purpose of this quantitative, quasi-experimental project is to determine to what degree the implementation of capnography during cardiopulmonary resuscitation (CPR) when compared to the current practice would impact the use of capnography during CPR for adult ICU patients at an acute care hospital in New Jersey within a four-week period. Nurses working in intensive care units, where the risk of cardiac arrest is high, are required to use evidence-based tools and strategies to reduce patient mortality (Israel, 2014; Jaffe, 2017). Capnography provides details about the patient’s condition and assists care providers in tracking changes in the patient’s condition to avoid complications (Heradstveit & Heltne, 2014; Pantazopoulos et al., 2015). Capnography proved to be effective in promoting increased patient outcomes in the detection of abnormalities associated with fluctuations in CO2 levels and following cardiac arrests (Cereceda-Sánchez & Molina-Mula, 2017; Chhajed et al., 2016; Darocha et al., 2017; Hassankhani, Aghdam, Rahmani, & Mohammadpoorfard, 2015).

The widespread application of capnography during resuscitation attempts within specific clinical settings has yet to be achieved due to the lack of specialized training that focuses on the project and understanding of its use (Dioso, 2014; Duckworth, 2017). This subject has not been addressed in the literature, specifically since most studies focused on the various applications and benefits of capnography. Hence, it is not known whether increased nurses’ knowledge of capnography is associated with improved use of this tool during cardiopulmonary resuscitation

The problem discussed above affects various patient populations who are at risk of a cardiac arrest, including patients in intensive care units as well as those with chronic cardiovascular conditions. The barriers to consistent implementation of capnography use within a critical care setting prevent care providers from delivering the highest quality of care, thus posing a risk for patients’ survival during a cardiac arrest. Hence, it is essential to explore the factors that could hinder the use of capnography in high-risk settings, as this would help to develop evidence-based strategies to enhance capnography use Evidence of a positive relationship between nurses’ knowledge of capnography, their readiness to use this tool, and the rate of capnography use during CPR would help to fill the gap in current literature expanding on the significance of these techniques.

Clinical Question

The following clinical question guides the present quantitative project: To what degree does implementation of an evidence-based intervention on use of capnography during cardiopulmonary resuscitation (CPR) impact use of capnography during CPR when compared to current practice, among adult ICU patients in an acute care hospital setting in New Jersey within a four-week period? This clinical question presents the two main variables that were explored in this DPI project. The independent variable is the implementation of an evidence-based intervention that centers on teaching nurses about the use of capnography during CPR. Consequently, the dependent variable is the expected outcome – the number of cases of CPR where capnography is used by nurses in the selected unit of the hospital, ICU (see Table 1).

Table 1: Characteristics of Variables

The project’s methodology is quantitative, and both variables are represented by numbers. For the independent variable, an existing instrument was used to measure nurses’ knowledge of capnography. Designed by Kiekkas et al. (2016), the Nurses’ Knowledge about Capnography Test (NKCT) provided a validated test for collecting data about the outcomes of the proposed intervention and the knowledge that nurses in the ICU possessed about using capnography. The design was selected as it aligned with the clinical question, and its questions directly addressed nurses’ potential hesitation and overall preparedness for using capnography during CPR. For the dependent variable, the Electronic Health Records was chosen as the main source of data, as it contained all necessary information about patients residing at the unit, the number of codes the unit had in regards to CPR, and how many times the use of capnography during resuscitation was registered.

The quantitative quasi-experimental was selected to answer the posed clinical question. First, the primary purpose of the project was to introduce an improvement to the existing practice, which implies the need for a quasi-experimental or experimental design as opposed to descriptive and correlational studies that examine existing relationships. Second, the investigator did not have the ability to randomly select the sample on assign groups due to the nature of the intervention. Thus, the experimental design could not be used for the DPI project, and the quasi-experimental design was the best possible option to answer the clinical question.

Project Methodology

The methodology selected for the project is quantitative; this is justified by the need to explore the subject from an objective viewpoint. The primary benefits of quantitative methods are that they provide accurate numerical information reducing the risk of bias. The quantitative methodology incorporates mathematical, statistical, and numerical analysis of gathered data using computational techniques (Valente & MacKinnon, 2017). The information can be collected with the help of surveys, questionnaires, and by using existing statistical data or health records and manipulating it with technology. This methodology provides an opportunity to answer the clinical question on the basis of objective calculations, which leads to data generalization across groups of people.

Additionally, according to Jones (2016), quantitative methods focus on providing a vast scope of information rather than on exploring some variables in-depth. This means that such methods could be useful in settings where there is a need to collect as much information as possible and draw sound conclusions from it. In the present case, gathering more information would benefit the project presented by providing more evidence of a connection or lack thereof between the variables and the effect that the intervention could have on the expected outcome. The data collected in quantitative projects is also simplistic in its nature, which makes it particularly useful for observing changes in variables, analyzing data for correlations, and presenting it for review and replication (Ali & Bhaskar, 2016; Heale & Twycross, 2015; Leppink, O’Sullivan, & Winston, 2016; Watson, 2015).

Quantitative data sources are particularly helpful in obtaining evidence about the effects of one variable on another, which was the primary goal of this project. It is more useful and practical than the alternative qualitative methodology for several reasons. In contrast with quantitative data sources, qualitative methods focus on obtaining meaningful information about the participants’ attitudes and beliefs and allow doing so by enhancing the depth of data collected (Austin & Sutton, 2014; Barnham, 2015; Flanagan, Greenfield, Coad, & Neilson, 2015; Gunnell, 2016). Qualitative projects focus on the participants’ perceptions rather than on objective information; they take information that is challenging to measure and draw specific themes based on individual views of the problem and related theories.

In this DPI improvement project, qualitative methods would allow one to explore nurses’ beliefs about their own knowledge about the implementation of capnography use in CPR and its importance. This information, however, would not show how an intervention could affect the use of capnography during CPR and patient outcomes connected to the change (Barnham, 2015). The dependent variable is quantifiable, and the quantitative methodology allows the investigator to see the relationship between nurses’ training and their decision making by analyzing the records and nurses’ knowledge.

The selected methodology is better suited to answer the posed clinical question in two ways. By allowing the evaluation of the level of knowledge about capnography objectively, in contrast with qualitative methods, and establishment of the effect nursing knowledge has on the practice could be examined. Given the nature of the problem at hand, evaluating factual knowledge is more important because it provides more information about the effectiveness of nursing education in capnography. Secondly, quantitative data obtained through the EHR would be more structured, thus making it easier to analyze how nurses’ knowledge translates into their practice.

Project Design

The chosen design for the quantitative project is quasi-experimental. As explained above, this is the most suitable design for the DPI project and the best fit for answering the set clinical question. A quasi-experimental design is similar to experimental projects in that it measures the causal impact of an intervention (Alessandri, Zuffianò, & Perinelli, 2017). However, in contrast to pure experiments, this design does not use a randomized population sample, assuming partial or full control over the sample’s selection instead. Moreover, the unique feature of one-group quasi-experimental projects is that they do not use a control group for comparison, using results from one sample group (Alessandri et al., 2017). Thus, the design allows for more control over the project, but some limitations and potential challenges arise.

The fit of the quasi-experimental design for the current intervention relies on its ability to directly address the clinical question. The latter explores the connection between nurses’ knowledge of capnography under the influence of intervention before and after the program has been implemented and the effect of this initiative on the use of capnography. According to Valente and MacKinnon (2017), the aim of quasi-experimental projects is to examine the impact of such change programs. Furthermore, the increased attention to choosing the sample implies the ability of the investigator to use their desired setting for the project and see how the intervention affects specific populations. In this case, the nurses’ participation in training makes them a necessary part of the project. At the same time, only patients who experienced cardiac arrest and required CPR could be eligible for the project, and randomization of the sample seems inconvenient for exploring the clinical question.

The role of quasi-experimental design is apparent in the variables outlined in the project – the number of resuscitations with the use of capnography before and after the intervention requires a highly specific set of patients in the hospital, the examination of which would be impossible when using other quantitative designs. Similarly, the chosen design explains the use of quantitative methodology and shows how numerical values can be utilized to answer the clinical question. Thus, it further supports the use of quantitative methodology as opposed to qualitative or mixed varieties.

Two sets of data were collected for examination based on the quasi-experimental design, as noted above. The first was the nurse’s knowledge of capnography using the NKCT to demonstrate the effect of the intervention (a training program for nurses about capnography use in resuscitation). The second one was the EHR data about codes that showed the cases of resuscitation in the unit and the use of capnography during these codes before and after the intervention was implemented. The quasi-experimental design allowed the investigator to collect data at points before and after the intervention, employing the pretest-posttest variety of the design, and compare them to demonstrate the effect of change and its significance.

Population and Sample Selection

The setting for the intervention is the ICU of a hospital located in New Jersey, where nurses are under increased pressure to deliver timely care and respond to situations that pose a significant risk to patients’ health. The ICU was chosen because these units have many patients whose health can deteriorate or change rapidly, and they require constant attention and monitoring. Nurses working in the ICU have to act quickly, assisting patients in an environment where each decision may be crucial to their health. Moreover, there is a high incidence of cardiac arrests, and thus nurses are often involved in cardiopulmonary resuscitation (Wright, 2017). The combination of these factors emphasizes the need for the proposed intervention, as the latter aims to increase the quality of care. As a result, the project’s results also present an opportunity for improvement and potential benefits for other units and locations.

The department under examination is a twenty-bed unit that employs 32 nurses and operates at an 8-10 bed capacity. While nurses working at the ICU are not the population for the project, this number is important for investigators as it shows the amount of preparation for training. For instance, this number demonstrates the capacity of nurses to perform CPR and respond to patients’ needs as well as how many days were required to implement the training program and assess nurses’ knowledge of capnography.

The project population includes all patients who were treated at the selected ICU during the project. The sample for the project is patients who experienced cardiac arrest and underwent resuscitation in the intensive care unit of the selected location. The inclusion criteria for the sample requires patients who are treated in the selected unit at the time of the project. Moreover, these patients have to have experienced the code situation (cardiac arrest) and underwent cardiopulmonary resuscitation as a result. Exclusion criteria for the sample are based on age – only adult patients who were older than 18 at the time of the implementation are considered to deliver results that could be generalized for a larger adult population (Mohamed, 2019). Furthermore, patients who had a cardiac arrest but did not undergo resuscitation were excluded as well. Reasons for not performing CPR could include a Do Not Resuscitate (DNR) order.

The size of the sample for patient CPR cases can not be determined preemptively as the number of cardiac arrests is not a measure that can be predicted. The conclusive records about the code situation and the use of capnography can be obtained only after the period of the intervention is over, thus finalizing the project sample size only after the four-week duration of the project’ phase. Nevertheless, the sample size is not controlled or restricted, thus demonstrating the flow of patients and case situations in an environment without the investigator’s influence. The number of nurses who need to complete the NKCT is 32 – as all nurses in the unit are required to attend training.

The selected sample size is rather small for a quantitative project because this design implies collecting data from as many charts and participants as possible (Cronin et al., 2014). This is because the size of the sample in this project is constricted by the geographical location of the project and the focus on intensive care units, which limits the number of cases available for the project. However, since the project does not follow an experimental design, which would require setting the sample size based on power analysis, the selected sample size will likely be enough for a quasi-experimental design (Cronin et al., 2014). Moreover, the focus on ICUs allows one to discuss the connection between the specific department’s setting and nurses’ skill and their treatment of patients.

The geographic specifications of the project mean that nurses will be recruited from a single state; in this case, New Jersey, where the evaluation of this DPI improvement project would be performed. Nurses will not have to travel to take the test; instead, all data collection procedures will be conducted at their place of work in a way that does not impair the workflow. Similarly, patients will not be disturbed to gather data about cases of cardiac arrest – EHR is the main source of information. All data will be anonymized to remove identifying information such as names and occupations.

Instrumentation and Sources of Data

There are two variables for which data has to be collected – the intervention which is described by nurses’ knowledge of capnography and the number of CPR cases with the use of capnography. The type of data for all variables will be quantitative, but the data will come from two different sources. This separation of the instrument and a source of data is required to show the effect of the intervention on the use of capnography.

The Nurses’ Knowledge about Capnography Test (NKCT). The NKCT will be used to collect the required data on the nurses’ knowledge of capnography. This tool was developed by Kiekkas et al. (2016) and included 30 correct and wrong statements about capnography.

The items are separated into four groups: principles of capnography function, conditions affecting end-tidal CO2 pressure, conditions affecting capnography waveform, and indications for capnography use (Kiekkas et al., 2016). The test will be delivered to all nurses identified through probability sampling (all nurses working at the selected ICU) and marked on correctness to determine the level of capnography knowledge. The test will be scored on a 30-point scale, and thus the results will be quantitative. The NKCT is an established tool for appraising nurses’ knowledge of capnography, thus making it an appropriate selection for this project as a test with proven results.

The Electronic Health Record (EHR) data about the code situation. The second source of data is the EHR of the selected ICU, which contains information about the patients treated at the hospital. The records document patients’ descriptions, including their age, gender, and ethnicity, which will be collected to make the data set more informative. The primary type of data, however, will be the number of cardiac arrests and resuscitations with and without the use of capnography. The data will be collected and stored electronically in an Excel spreadsheet to ensure that each instance is properly documented. The number of code situations with CPR will be recorded as a cardinal number, and each instance of CPR will have a descriptor of “1” and “0” to denote the use (or non-use) of capnography. Thus, the final type of data will be a ratio.

The use of the EHR has high validity and reliability as health records are the main place for the hospital to gather all data related to patients’ health (Lin et al., 2018). It is an official source of information that is handled by the staff, which implies that all code situations have to be in one place. The permission from the hospital to collect and use data will be obtained, and the data will be anonymized to ensure participant’s privacy – patient’s names will be replaced with numbers, and only their age, gender, and ethnicity will be collected to avoid potential identification.

Validity

The NKCT has already been evaluated for its validity specifically in its use to construct validity using techniques designed to test the relationship between NKCT and the knowledge base of nurses in capnography (Kiekkas et al., 2016). The authors used nurses’ experience in the anesthesiology department and the date of introduction of capnography to the said department to determine nurses’ capnography experience, whereas education levels were derived from nurses’ qualifications (Kiekkas et al., 2016). The authors concluded that the evaluated construct validity was high because both characteristics had a positive effect on the NKCT scores as predicted (p=0.038 and p=0.003, respectively). Hence, the use of an instrument with high construct validity will ensure that the data collected on nurses’ knowledge also has high validity.

Secondly, the validity of EHR data depends on the fulness of patient information. According to Lin et al. (2018), high data completeness increases the quality of gathered information and improves the results of the analysis. Most problems arise when projects require patient information from different provides or out-of-hospital situations (Lin et al., 2018). Acknowledging the fact that the present project uses a small part of patient data that pertains to their treatment at the single unit, the validity of the data gathered from the EHR is high.

The DPI project requires only a small set of descriptive characteristics (age, gender, ethnicity) and the code for cardiac arrest and CPR with or without capnography. All needed information is recorded by staff of the department or administrative personnel, and the participation of clinicians outside of the hospital is not necessary to collect this data. Thus, the factor of EHR-continuity does not have a significant influence on the results of the data collection process. The use of the validity score developed by Lin et al. (2018) is, therefore, not needed to ensure the fulness of information, as is does not affect the clinical question’s outcome.

Reliability

Similar to the instrument’s and data source’s validity, the reliability of both data collection methods will be assured to provide reliable outcomes. Concerning the NKCT, the test’s reliability has already been evaluated by its creators. Kiekkas et al. (2016) note that they applied internal consistency and item analysis to determine the reliability of the instrument. Kuder-Richardson 20 coefficient was used based on the type of the test (dichotomous choices). The point-biserial correlation index was also applied, yielding the results from 0.168 (poor item discrimination) to 0.833 (excellent item discrimination), with most items (28 out of 30) having either good or acceptable discriminatory value (Kiekkas et al., 2016). This means that the internal consistency of the test is high, which allows it to collect data with a high degree of reliability. The internal consistency was supported by intra-rater reliability evaluation. Both tests used by the authors provide an adequate degree of certainty, which is why they are used to ensure the reliability of data collected using this instrument.

Data Collection Procedures

Before the data collection begins, obtaining institutional approval from the selected hospital to conduct tests and observations in intensive care units is the first step in initiating the process. Once the approval has been received, data sources requiring a list of all nurses working in the intensive care unit of the selected hospital would be obtained. This would form the basis of the project to access the knowledge of nurses’ working in this setting from a quantitative perspective. The nurses involved in the project will be contacted by e-mail, and information about the results and findings would be explored in detail. The project of nurses knowledge and capnography through quantitative evaluations in the use of the institutional provided data source analysis tool, in addition to the NKCT, have been performed with the relevant documentation and procedures ensuring privacy and confidentiality of the nurses partaking in the project (Cronin et al., 2014; Price et al., 2017).

Due to the nature of the pretest-posttest design, the data collection of nurses’ knowledge of capnography should be completed before and after the educational program has been completed by the participants to demonstrate whether the intervention had an effect on nurses’ perception of capnography. It will employ the NKCT to examine the independent variable in the project (Kiekkas et al., 2016). All participating nurses working within the ICU setting will take the test in a controlled environment, such as in a conference room. The test will be completed either after the nurses’ shift or before so that it would not disrupt their workflow. For any nurses who have difficulties in scheduling, the test will be conducted individually.

The second part of data collection will involve using the hospital’s EHR to gather information about patients and instances of CPR. As noted previously, a small set of patient descriptions is necessary to make the data set more informative. Adding such information as one’s gender, age, and ethnicity can present valuable findings for future studies and show whether the sample is heterogeneous and suitable for generalization. Moreover, each instance of cardiac arrest with CPR will be recorded, noting which of the cases involve capnography. This information for the pretest examination will be collected 28 days prior to the start of the program to form a set of comparative baseline data. The second set of data (for posttest analysis) with similar contents will be requested at the end of the program (28 days after the start of the program). As the data will be collected from digital recordings, minimal manipulation will be necessary to standardize the information and present it in an Excel spreadsheet.

Both data sets do not require informed consent since the intervention involves all nurses, and patient data is collected through the EHR. Nonetheless, the agreement with the hospital about the amount and types of data provided will ensure that the investigator has access to the necessary information. As mentioned previously, all data will be anonymized, and the results of the NKCT and EHR data gathering will be coded to exclude any uniquely identifiable information such as names or positions. The data will be stored digitally or a password-locked computer and destroyed in one year after the end of the project.

Data Analysis Procedures

For the purposes of the present project, data on two variables will be collected: nurses’ knowledge of capnography before and after the intervention and the use of capnography during CPR. For the first variable, quantitative data will be collected using the Nurses’ Knowledge on Capnography Test. For the second variable, quantitative data will be obtained from the EHR (BETP, 2017; Kiekkas et al., 2016). The clinical question to be answered using data analysis is to what degree implementation of an evidence-based intervention on use of capnography during cardiopulmonary resuscitation (CPR) impacts the use of capnography during CPR when compared to current practice, among adult ICU patients in an acute care hospital setting in New Jersey within a four-week period.

Data analysis methods are critical to quasi-experimental pretest-posttest data studies in that they assist in determining any effects that the independent variable may have on the dependent one. Firstly, the difference between pretest and posttest values has to be determined to show whether change happened during the intervention. The use of two measurement points – before and after the intervention – for both variables implies the need for a t-test. The t-test is used to compare the mean of two given samples when the standard and mean deviation are not known (Alessandri et al., 2018). For this case, a paired sample t-test is required to compare the numbers for one group at different points in time.

For the first variable, the t-test will denote any differences between nurses’ scores on the NKCT – two sets of raw data will be collected from the surveys by hand and input into processing software. For the second variable, the rates of code situations with the use of capnography out of all code situations will be calculated and input into processing software. It is essential to present the data in the form of rates, since the initial numbers of resuscitations with capnography may not represent the overall rate of CPR instances during the two periods of data collection. Thus, to start the analysis, the number of code situations of CPR with the use of capnography will be divided by the overall number of CPR during cardiac arrest. This calculation will provide two sets of data, which then can be compared using the t-test to demonstrate a change in the use of capnography over time. The level of statistical significance for the project is set at p=0.05, which is a standard level used in many studies in nursing (Cronin et al., 2014).

The improvement from the results of pretests to the outcomes of posttests is calculated using the Gain score. The results are achieved by subtracting the first score from the second one; positive scores demonstrate gain, while negative scores show loss of knowledge or use of capnography. This data analysis method will help to answer the clinical question posed for the project by identifying the change of nurses’ capnography knowledge and their use of capnography. The information regarding the level of change will also be necessary for examining nurses’ knowledge of capnography use.

For example, if the identified gain is positive and very strong, nursing education that aims to increase nurses’ capnography knowledge is likely to result in significant improvements in the use of capnography. Therefore, the quasi-experimental design will formulate answers by providing meaningful information that could be used in practice improvements. The use of specific statistical tools, such as XLSTAT, will help to ensure the correctness of calculations while also supporting the data analysis process. The chosen data analysis procedure also relates to the purpose of the project as it will explore the possible relationship between nurses’ knowledge of capnography and their use of this tool during resuscitation in great depth.

Potential Bias and Mitigation

The potential risk of bias exists in the stages of data collection and analysis. Taking the test in a controlled environment is important to reduce the risk of bias (Price et al., 2017). If nurses were to take an online test, they would be able to search for additional materials, thus showing a higher level of knowledge than they possess. Hence, the proposed procedure will have a beneficial impact on the quality of the findings. Each test will be completed in the intensive care unit, on paper and marked with the nurse’s identification number to prevent bias in quantitative data results. It is vital to note that nurses’ names will not appear on paper, lowering the risk of a privacy breach.

Another point of bias is the calculation of changes before and after the intervention. The use of the rate of capnography use in comparison to the overall number of CPR is necessary to mitigate this risk as the unit may have vastly different numbers of code situations, thus producing varying results of capnography use. However, the chosen setting implies a high number of CPR performed in the unit, thus lowering the impact of this concern on the project.

Ethical Considerations

The present project involves human subjects, and it is particularly important to protect their rights and conduct the project in an ethical way (Sanjari, Bahramnezhad, Fomani, Shoghi, & Cheraghi, 2014; Zyphur & Pierides, 2017). The key ethical issues relating to the project are the confidentiality and privacy of personal information provided by the participants and the disruption of nurses’ workflow during the project. Both problems mentioned above violate the principles of the Belmont Report since they might cause harm to the nurses and their patients.

In order to address these issues, the project was modeled in a way that minimizes workflow disruptions.

For instance, testing will take place outside of the nurses’ shifts, and data collection will be conducted from the EHR without disturbing patients or staff. Additionally, measures to protect data privacy and confidentiality will be applied. Personal information about the participants will be stored safely on a password-protected device and destroyed after one year by deleting electronic documents and shredding paper documentation. Identifying information, including names and e-mail addresses, will be replaced with identification numbers during data collection and analysis. No contact with patients will be made throughout the project, so no harm to them will be caused.

IRB approval to conduct the project will also be received, which means that the project will be done on a voluntary basis, and nurses will participate based on their motivation. The documentation will provide all relevant information about the project, including the ethical measures taken to protect the participants, their work, and data. No potential conflicts of interest were identified at this stage since the investigator is not connected to the hospital or nurses who will participate in the project. As the project may be published in scholarly journals, precautions will be taken to protect subjects’ privacy and confidentiality at the publication stage. The documents shown to third parties will be checked to ensure the absence of identifying information, and the publication will only reveal the findings and will not contain any identification numbers.

The data shared by the institution and the nurse participants will be stored securely on a password-protected computer, and the participants’ numbers will be used instead of their names during data collection and analysis. The data will be held for one year following the end of the project and will be destroyed. Explanations into the project’s premise would be presented in their entirety to the nurses, and e-mail verification solidifying understanding into the proposed clinical question would prove useful for the setting presented. These precautions are in accordance with the European University Institute guide on data protection practices, and they will help to ensure that the participants’ rights will be preserved throughout the duration of the project (EUI, 2019). Additionally, it is important to note that no contact with patients will be made during the project, and thus patients’ health and well-being will not be affected by the project in any way.

Limitations

While the project has been carefully designed to provide high-quality information on the problem and avoid bias, there are still two limitations related to its methodology. Firstly, the sample size of the project is smaller than in other quantitative studies in nursing (Cronin et al., 2014). New Jersey was chosen as the site of the project because of the need to conduct observations, and thus moving the project to another state would not be feasible. Additionally, the focus is on an intensive care unit, limiting the number of nurses in the sample. Enhancing the scope of the project would not help to achieve project goals because most other groups have a lower frequency of cardiac arrest and would thus provide incomplete data. Hence, the chosen sample size is the best option given the geographic location of the project.

Another limitation is the facility under investigation has only two portable capnography monitors available, which means that nurses will be able to use capnography in two simultaneous code stations. However, it is reported by the unit’s representatives, that it is rare for more than two codes to happen at the same time, so this limitation presents a low risk to the project. If a third code were to occur, the project’s results could be influenced, and these instances have to be recorded to ensure transparency.

Conclusion

The purpose of this quantitative quasi-experimental project is to explore the impact of nurses’ knowledge of capnography on their capnography use during CPR in intensive care units. The quantitative methodology is the best fit for the project’s purpose because it will provide objective data needed to establish the relationship between the variables (Barnham, 2015; Cronin et al., 2014).

Additionally, the quasi-experimental pretest-posttest design of the project is tailored to the needs of the project because it focuses on establishing the level of change and the relationship between the two variables (Curtis et al., 2016). The data collection procedures that involve conducting surveys of nurses’ knowledge about the appropriate use of capnography through NKCT and data gathering from the EHR will provide adequate measurements of the variables presented (Kiekkas et al., 2016).

Descriptive statistics, t-tests, and gain scores will also be applied to draw conclusions from the data sources provided as well (Price et al., 2017). The sequence of procedures chosen for the project will help to respond to the clinical question and fulfill the purpose of the project in evaluating and improving clinical practice.

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Introduction

Today, an essential role in improving the effectiveness of medical care is assigned to specialists with secondary and higher nursing education. Nurses make up more than half of all healthcare workers globally and provide vital services at all levels of the healthcare system. However, the staffing of medical organizations with nursing specialists is decreasing annually. The so-called global crisis of nursing personnel is associated with many factors, including low wages and an exorbitantly high workload. The number of patients in some hospitals is ten times the number of nurses, so they do not have the opportunity to use various affordable, cost-effective nursing services. Internal conflicts, lack of support from the administration, and organizational culture are also reasons for personnel losses. In addition, as a result of optimization of nurses, paramedics, and midwives, there is a negative personnel dynamic of the average medical staff in the primary care unit.

The problem with the shortage of nurses is observed in many countries, including European ones. In some medical institutions, there is an average of 25 patients per nurse, often more. This is five times higher than the standards of the World Health Organization. The shortage of nurses is becoming more noticeable as forced hourly overtime, and additional shifts become the norm. The clinic staff is forced to work hard because there is no one to replace them. Wages remain low; because of this, nurses, trying to increase income, work at the limit of their capabilities, and sometimes beyond. They experience chronic fatigue; it is easy to make a mistake in this state. Given the importance of all of the above factors, the purpose of my work is to determine whether the allocation of nurses and patients is adequate to provide quality services.

Due to the heavy workload and stress associated with exceeding the number of patients per medical employee it is possible to distinguish many negative trends among them. These include irrational use of medications, depression, fear of work, skipping work, leaving a job, reducing responsibility for patients’ health, and making mistakes in treatment. In addition, such problems as low salaries of medical workers compared to their work and workload are significant, which causes higher turnover and withdrawal from this industry. This shows that the problems of labor assessment, workload, and management of the medical sector remain the most urgent and acute. Too many patients and the associated limited amount of time for an appointment reduces the motivation of a medical specialist and can harm the quality of medical care. Considering the above, this research was conducted to study the modern system of the workload of average medical workers. In addition, the distribution of time per patient is of interest for forming the most favorable conditions aimed at stimulating the quality of work of a nurse.

The lack of personnel causes an uneven distribution of job responsibilities; the total workload in medical institutions varies depending on staffing levels. Thus, this serves as an additional factor in the uneven distribution of medical services and workload. Another acute problem is that the staffing of specialists in medical institutions is approved based on the practice of previous years. Since hardly any studies of workplaces or job descriptions are supported, nurses do work that is not part of their direct functional responsibility. They do not perform specific tasks, and as a result, it turns out that nurses do not have the opportunity to devote enough time to each patient (Krisda et al., 2019). This situation makes it difficult to plan what specializations, experience, or skills will be needed for specific job functions. This creates difficulties in planning, organizing, and conducting training and activities to develop nursing care. According to a single standard, this can make it difficult to assess and measure the workload and, consequently, the distribution of time among patients.

Nurses’ workload varies depending on the main activities, type, category, and level of medical organizations, and its location. The actual workload and wages, as an assessment of their work, are not comparable. However, it is possible to identify general trends that concern most nurses. For example, this is the lack of work on human resource planning, the study and analysis of actual conditions, or feedback control. As a result, the total workload is unevenly distributed among the staff, and the staffing table is not observed.

Today, a nurse should act as an organizer of conditions for maintaining and restoring the patient’s health, consultant, and direct executor of measures to achieve the goals set. To do this, it is necessary to define a new role of a nurse in the treatment process. This implies a clear delineation of the duties of a doctor and a nurse, and the introduction of precise load standards for a nurse. The nurse can no longer remain a technical executor of the doctor’s instructions; they must become partners acting independently within their competence. One of the aspects of this multifaceted problem is the study of the functioning of the outpatient care system for the population. The role and importance of this system are increasing in the context of the transition of healthcare institutions to new economic relations. Within the framework of this new approach people are served on the principle of insurance medicine. One of its main components is allocating the time needed to provide quality nursing services to each patient.

A nurse should be able to solve the patient’s problems, make decisions, determine the amount of care, plan, implement it, and evaluate the quality of nursing care provided. The provision of medical care in the primary unit is a tremendous amount of work. This work must be optimally divided between the doctor and the nurse. Thus, it provides an opportunity to focus on issues of diagnosis and treatment for the doctor, and the nurse can devote a sufficient amount of time to patients. A unique side of nursing care, closely related to the above aspects, is the moral and ethical side of the relationship between nurses and patients. The psychology of the relationship between health workers and patients is noticeably affected by the lack of time for nurses. Few have the qualities necessary to establish communication with patients in too short a time.

To improve the quality of work of a nurse, it is necessary to release them as much as possible from work that is not directly related to the patient. It is required to investigate the possibility of rational distribution of responsibilities with a delegation of authority from the doctor to the nurse. That will provide the nurse with enough time for every patient. To fulfill these tasks, a rational organization of the work of nursing staff and a precise distribution of working hours is necessary. In addition, during the period of changing socio-economic relations, the importance of the psychological component in the relationship between health workers and patients is sharply increasing. Therefore, the availability of time for nurses to establish contact with the patient is critical.

The experience of medical and preventive institutions shows that with a sufficiently high clinical effectiveness of medical services, their economic efficiency is often low. This is due to the fact that medical personnel are not always used rationally and cannot efficiently distribute time between patients. With a high annual turnover of beds, the recommended number of doctors and nurses is most often not observed in various departments. This leads to an increase in the workload of procedural nurses, which, in turn, results in reducing their time for patients. Excessive workload reduces job satisfaction: workload may not allow the procedural nurse to promptly respond to patients ‘ requests.

Thus, the significant losses of working time that could be allocated for interaction with the patient are often associated with work disorganization in departments. To achieve high labor productivity in health care facilities at each workplace, it is necessary to identify and eliminate the factors that lead to unproductive time losses. Perhaps, to increase the time allocated to the patient, it is essential to involve a nurse with higher nursing education in this work. They should be guided by modern theories of leadership and management and can ensure the practical work of departments and institutions.

The right of citizens to receive care when providing them with medical care is guaranteed by law. The priority of the patient’s interests is carried out, among other things, by providing care during medical care. However, unfortunately, the legislator does not disclose the term “care”; therefore, there are still no criteria for a shortage of care approved at the departmental level. Nevertheless, it is possible to consider the lack of allocation of the proper amount of time to the patient as a criterion of improper care.

The timing of the work of ward nurses shows that there is not enough time in the nurse’s work schedule to carry out the most direct patient care. Therefore, it is necessary to involve relatives or paid staff to provide care for seriously ill patients. Nurses in many countries complain about the lack of time to perform the procedures required for patients, as evidenced by numerous materials of nursing sites on the Internet. Thus, the problem of patient care is acute not only in the USA: for example, a massive scandal broke out in the UK. It happened due to the fact that it turned out that more than 3 thousand patients died in British hospitals due to lack of proper care.

Solving patient safety problems related to the amount of time spent by nurses in the country, of course, requires a solution at the government level. The legislator represented by the US Department of Health should provide physicians with a regulatory framework for care and adopt norms of care. By these standards, labor standards should be developed that includes a minimum amount of time per patient.

A lack of time resources also causes the increase in nurse errors recorded in recent decades. When studying the working conditions of nurses, it was singled out among the main factors that increased the risk of making mistakes. For example, this is due to the fact that during the patient’s admission, nurses solve various spatially scattered and short-time tasks. They are constantly distracted by external signals, such as phone calls, and calls from other patients. In addition, due to urgent orders of doctors, they often have to interrupt the reception of patients.

Under these conditions, no more than a quarter of the nurse’s working time remains for interacting with patients. However, this problem can be alleviated in departments and wards where the work of nurses is well thought out and organized. Walking takes less time, and the number of random disconnections from receiving the patient is significantly less. A good work organization is characterized by a clear division of functions between nurses, the correct layout of wards, and the allocation of functional sectors. Thus, even if there is a need to distract, the time deducted from the care of a particular patient is insignificant.

In addition, the reason for the uneven distribution of time between the reception of patients and other responsibilities may also result from another factor. The imperfection of information support for the work of ordinary medical workers strongly affects it. All over the world, the problem is the loss of information during the transfer of shifts. Few hospitals can boast clear regulations for transferring data from the nurse taking the change to the nurse taking the growth.

Illegible handwriting in the list of appointments, inarticulacy of information on numerous labels and labels takes a lot of time. It is proved that a well-readable title should have a matte surface so that glare does not disrupt visual perception. Unfortunately, no more than half of the drug labels meet these requirements. Packaging design is essential: it is unacceptable to have the same packaging design for different drugs. It is hazardous if the packaging of the same drug, but in different dosages, is no different.

The problem of recent years is errors when working with a computer. Very often, programs have an inconvenient, poorly readable interface, complex search systems. In this case, the laptop only complicates the nurse’s work, increasing the expenditure of time resources. Of course, this does not mean that it is necessary to abandon the computerization of nurses’ workplaces, but it should be done thoughtfully for a minimal time.

Labor rationing should also deal with their optimal proportions when performing a particular job, planning certain areas of health care development. This implies the need for a nurse manager who purposefully improves their ability to manage. They must have an objective attitude to introducing new working methods, making modern decisions, and a professional view of each specific situation. Rational planning of the labor process is also necessary to increase productivity and quality of labor.

The timekeeping measurements can make it possible to determine the average duration of individual labor operations and the structure of the working time spent by the heads of nursing services. The data of the time-based assessment of various types of work of senior nurses can be a methodological basis for developing recommendations for improving the regulatory framework of their activities (Foo et al., 2017). In the absence of approved estimated norms of time spent on a particular type of activity, they can be developed on the spot and agreed with the institution’s administration. Many issues of labor rationing in the healthcare system have not been resolved. Thus, the regulatory documents do not define the time spent by the heads of nursing services, complicating the allocation of time resources for patient care.

Nursing staff, on which the quality and effectiveness of medical services largely depend, plays a crucial role in solving the tasks of medical and social assistance to the population. American healthcare faces the task of continuously improving the quality of medical care. The solution to this problem should be accompanied by a constant reduction in the cost of medical services. Improving the quality of medical services is determined mainly by nursing participation in the treatment process and the time allocated to patients.

It is known that nursing staff contacts patients more often, so at this level, patients’ perception of the quality of medical care is formed. Therefore, improving the efficiency of the healthcare system mainly depends on the effectiveness of personnel and time resource management. The average medical staff is the largest group of medical workers. The quality of medical care and patients’ satisfaction with it depends on the efficiency of the time allocation of their activities.

Factors such as excessive filling of medical documentation and lack of time to attend scientific conferences and study medical literature have a negative impact on professional activity. It is also extremely important to have a high psychological burden, a mismatch of wages for the services actually provided, and a shortage of average medical staff. The effectiveness of treatment is the impossibility of a thorough examination of the patient as a result of too many patients per nurse.

The activity of a nurse is associated with increased psycho-emotional stress combined with responsibility in decision-making in various extreme situations. Nursing staff in the course of their professional activities are often exposed to various negative factors. These include excessive physical and psychological stress associated with too many patients. Health workers overloaded with the number of patients are more likely to have symptoms of depression, anxiety, insomnia and distress. They have high levels of anxiety, stress, and not very good sleep quality.

The nurse has to carry out leadership, educational, educational activities. They promote the practice of a healthy lifestyle, physical and mental hygiene, help the patient to develop. One of the principles of a nurse’s work is that a nurse should be empathetic. At the same time, empathy often turns into a quality that a person should possess regardless of circumstances. Along with the need to have appropriate feelings, the nurse often has to hide her spontaneously arising natural feelings that do not correspond to the situation. A lot of effort is spent, for example, on suppressing feelings of irritation, fatigue, anger that arise when communicating with a patient. Their manifestations become more pronounced when it is necessary to switch frequently and quickly from one patient to another.

Negative emotions (fear, irritation, despair) that arise in a nurse during or after work are often associated with negative experiences of the patient. The poor condition of the nurse is, as it were, a consequence of emotional involvement in the negative experiences of the patient. A large number of different situations, schemes and ideas about life that a nurse encounters often worsen the emotional background of an average medical employee. At the same time, in conditions of compressed time, there is often no possibility of generalizing and systematizing one’s experience, working out emerging communicative problems. One of the first places of specialties at high risk of emotional burnout syndrome is occupied by the profession of a nurse. When faced with negative emotions, the nurse unwittingly becomes involved in them, which is why they begin to experience increased emotional stress themselves. Most of all, people who have an excessively high level of workload at work are at risk of this phenomenon.

The causes of fatigue and nervousness can also be called exceeding the standard number of patients, a large amount of clerical and design work, low technical equipment of workplaces. Of the ergonomic factors, the nurse most often notes the strain of vision, overload of the musculoskeletal system. most medical workers have irregular working hours, overtime work associated with the combination of positions or additional professional workload. Low wages in a developing market economy forces nurses to work, often neglecting the time provided for restoring the physical and emotional balance of the body.

Thus, the timing of the work of nursing staff and the distribution of time and number of nursing staff is critical. Therefore, in this study, special attention will be paid to the main reasons for the decrease in the time allocated to patients. First of all, these are excessive workload, insufficient staffing, and the lack of temporary standards of medical care.

Literature Review

Review of ‘Factors Influencing How Intensive Care Unit Nurses Allocate Their Time Show Less’

This article shows the importance of the amount of time devoted by nursing staff in the intensive care unit to maintaining health and the quality of patient care. It identifies factors that change nursing care priorities in the direction of giving less time to one patient. Attention is paid to various labor costs of a nurse, caring for patients, and the percentage of the duration of their performance. For example, the amount of work with documentation, searching and viewing the results of tests and outpatient records at an appointment with a doctor is studied.

The study aims to calculate the average time spent by the intensive care unit nurse and identify factors that do not allow them to devote patients enough time. It was also planned to focus on activities that are not directly related to the provision of medical care to patients but are included in the functional duties of nurses. The study was also aimed at determining the average estimated time of an intensive care unit nurse for servicing one patient. Time costs should also have been taken into account, depending on the provision of medical care.

The study used an empirical medical method: intensive care unit nurses were monitored and then their working day was described. The study was designed to calculate the average time per nurse visit. The variables were the nurse’s tasks, which can affect the amount of time spent on the patient. Data collection was carried out by monitoring the nurses’ working day, and the analysis of this data was carried out by tabulating it and using simple mathematical calculations.

The strengths of this study are the consideration of a large number of factors and a diverse sample, which included intensive care unit nurses from different hospitals. The present study determined the scope of nursing interventions in patients in the department of anesthesiology and intensive care. At the same time, large psychological and physical loads, dynamics, and saturation with extreme situations were also taken into account. The data calculation was carried out under conditions of intense attention and responsible fulfillment of the doctor’s prescriptions.

The value of this study is that it describes in detail the work schedule of the average medical staff of intensive care wards in compliance with internal safety regulations. Also, the conducted calculation made it possible to establish the actual number of patients per nurse. This factor is essential when organizing intensive monitoring of patients and their treatment. The obtained dependence of the number of patients and the performance of post, procedural and operational duties is essential in forming the hospital’s medical team.

The main conclusion of this study can be considered ways to optimize the work of nurses in the intensive care unit. An essential role in optimizing the work can be played by the impact on resource-intensive parts of the activities of nursing staff. This includes the implementation of medical appointments in their simplification and the elimination of polypragmasia and other things. It is also proposed to use large-capacity solutions in the infusion therapy program, significantly reducing the time and resources spent on changing vials.

These conclusions apply to the topic of my work, as they affect an important area for optimizing the activities of intensive care units. The measures proposed in the research are aimed at increasing the time that will fall on patient care. For example, in the light of the trend towards the openness of departments, the possibility of involving relatives of patients in inpatient care should be considered. It is assumed that this will unload nurses and allow the patient’s relatives to gain skills that can be useful in case of his long-term dependence on outside care.

Review of ‘Nursing Workload, Nurse Staffing Methodologies and Tools: A Systematic Scoping Review and Discussion’

This article touches on a more specific aspect than the previous one. It examines the working hours and rest hours of nurses and special rules for part-time work. Documents regulating the result of a medical worker and the number of patients per nurse are also being discussed. Attention is paid to methods that allow reducing the intensity of psychophysical loads due to the specifics and nature of medical and other activities to protect public health.

The purpose of this study is to identify the rate of patient admission for a nurse. In addition, the tools are identified, which allows the organization of the work process of employees of a medical organization. They are aimed at excluding or minimizing fluctuations in the time of performing actions by individual specialists in one working room. The most effective tools of aggregation and visualization of information for operational management and monitoring of medical care processes in a medical organization are also determined.

A theoretical research method was used, namely general logical methods (analysis and synthesis). This scientific work is designed to measure the effectiveness of human resources in conditions of increased workload. The variables are the number of patients and the nurse’s ability to work. Data collection is carried out during scientific papers on this topic; their analysis is fulfilled using synthesis. The strength of this study is taking into account the management methods of a medical organization and its logistics system. It considers the relationship between patient flows, the quality of medical care, and the involvement of nursing staff in improving processes. The problem of the intersection of patient flows which leads to an increase in the workload of nurses is raised.

This study is valuable because it offers an effective solution to reduce the flow of patients per nurse. It is proposed to draw up a diagram of the movement of patients, analyze their routes, and then determine the number of intersections in the flow. Next, separate entrances for departments where intersections are detected can be created (Foo et al., 2017). The methods proposed in the study are practical tools to reduce the workload on the nurse.

The study’s main conclusions were the need to map the processes that are an integral part of providing medical services. Thus, it will be possible to identify the intersection of patient flows, increasing nurses’ burden. The conclusion also indicates the need to correct the sequence of actions of the patient in the flow of the passage process. The necessity of the line of activities of the nurse in the provision of medical care is proved.

The conclusions obtained in the study apply to this work, as they affect the causes of the uneven allocation of patients. The reduction of the queue and the unified schedule of specialists of the polyclinic or hospital increases the efficiency of the use of human resources of the medical organization. Thus, the nurse saves time on providing services, and the patient does not stand in line. With the help of electronic queues, all the needs of patients are closed, and nurses’ workload is unloaded.

Review of ‘Capacity Constraints and Time Allocation in Public Health Clinics’

This study considers the problem not from the point of view of a nurse, as the previous article, but from the point of view of the management of the institution. It discusses the justification of introducing time for one patient to visit doctors of various specialties. This phenomenon is correlated with an increase in the workload of nurses and a drop in the availability of medical care. The lack of time and resources for interviewing, examining the patient, and getting acquainted with their medical history is being raised. It is also said that nurses need to have high cognitive abilities to switch from one patient to another quickly.

The purpose of this study is to find a solution to combat the outflow of nursing staff from public clinics associated with the increased workload. The study is aimed at finding the optimal amount of time that nurses devote to the patient. At the same time, the goal is also to prevent the abuse of this time, for example, filling out dispatch sheets at the reception instead of receiving patients. To do this, the time is searched in the schedule for working with papers.

The study uses an empirical research method: analyzing various scientific sources of information and a sample of data. The study is designed to establish new standards for nurse appointment times. The variables are the number of minutes that can be given to one patient and the capacity constraints of the nurse. Data collection is carried out by studying reliable sources, and the analysis of the information is obtained by searching for confirmation and similarity of materials from different sources.

The strengths of the study are the scientific justification of the obtained standards based on chronometric studies. The proposed solution reveals the problem of the need for nurses to devote more time to the patient. A nurse should spend exactly as much time on a patient as the state of a person’s health requires. To calculate the load on the average medical staff, it is necessary to consider their work correctly. The number of specialists in public hospitals who must meet the population’s needs for a specific type of medical care also plays a role.

The value of the study lies in a practical algorithm for calculating the norm of the nurse’s appointment time, depending on the number of nursing staff and the patient’s condition. The time of the primary and repeated visits of the nurse is differentiated. After analyzing the nurse’s actions when receiving a patient, the necessary amount of time is allocated. It also takes into account the time that the nurse spends working with documents and other activities.

The conclusions of this study are the need to calculate and approve the maximum time spent by a nurse per patient in each specific public clinic. The regulatory framework for the admission of patients should be determined by the number of nurses and their average monthly workload. There should also be a separate time for filling out documentation. These standards of time for receiving patients are necessary to calculate the load on nurses.

The conclusions apply to the topic of this study, as they enable the economists of a medical institution to calculate the number of nurses needed to serve patients. In addition, after the calculation, these data can be used to predict the need for specialists in this profile based on morbidity statistics and regulatory load. In addition, the results will also help take into account the demand for a specialty in medical universities.

Review of ‘A Comparative Study of Patients’ and Nurses’ Perceptions of The Quality of Nursing Services, Satisfaction and Intent to Revisit the Hospital: A Questionnaire Survey’

This article contains more data obtained experimentally than the previous one. It allows to get an assessment of the quality of the nurse’s service. This involves the analysis by patients of their professional knowledge, skills and abilities, compliance with professional requirements, and qualifications. Patients also evaluate the quality of the final outcome of an individual treated by a nurse for a certain period. Attention is paid to the importance of nursing technologies, compliance with standards, and the specific situation (hospital or polyclinic care).

The objectives of this article are to establish the compliance of nursing activities with existing standards, protocols, or accepted norms of the organization. The search for qualitative criteria, from the point of view of patients, care, preparation for diagnostic procedures, rehabilitation is carried out. Also, the goal is to establish compliance of the achieved results of nursing activities with the planned ones. Patients should carry out a final control and evaluate the results achieved after the service is provided.

The research method was a survey; a written questionnaire of patients was used. The study was designed so that patients could help determine the criteria for quality care, including the amount of time devoted to a particular patient. The variables were patient satisfaction with the quality of nursing care, the time spent on patient admission, and healing outcomes. After collecting data through a survey, their analysis took place during the formulation of its results in text, diagrams, and tables.

The strengths of this study are a practical algorithm for ensuring the quality of activity by nurses themselves. This were an incentive for awareness of problems, desire for changes, formulation of a standard, including temporary, and changes in the implementation of measures. The conclusions of the examination gave a comprehensive decision on the quality of nursing activities. If a defect is detected, its type is determined, it’s causes, for example, insufficient time to devote to patients and the nurse’s reboot, and the consequences.

The value of this study lies in the establishment of dependent and independent causes of defects in the quality of nurse services. The level of satisfaction of patients, relatives, a society with nursing services did not meet the consumer’s expectations for various reasons. One of the most common independent causes of defects in the quality of nurse services was a shortage of time resources and medical personnel. Due to the combination of these factors, the nursing care provided does not meet the needs of the patient or population, their expectations, the current level of medical science and technology.

The conclusions of this study demonstrate the need to improve the quality of nursing care, including with the help of additional human and time resources. Objective reasons were identified that determine the need to ensure the quality of nursing care and the level of public health. Firstly, it is the consumer’s rejection of medical services with a relatively low level of quality. The second reason was the tightening of the requirements for improving the effectiveness of nursing care as a condition for the functioning of a medical and preventive institution.

The conclusions are essential for this topic since one of the ways to improve the quality of medical care was to increase the time allocated to the patient. Thus, nursing services for the organization and measures to preserve the patient’s health will be performed more efficiently. Patients will increase their satisfaction with performing manipulations, preparing for research, and conducting rehabilitation activities. The conclusions show that it is necessary to strive for an optimal ratio of the expectations of the patient and the time and attention paid by the nurse.

Review of ‘Senior Nurse and Chief Exec Pay Gap Widens’

Unlike the articles discussed above, this article also takes into account the issue of nurses’ salaries, which vary significantly in different regions. The influence of experience, skills, seniority, qualifications, and additional education on labor remuneration is noted. On average, there is a gap in the salaries of nurses and other specialties in the country. Although the income received is enough to live with dignity and support a family, the nursing profession is not highly paid.

The purpose of this article is to compare the workload of a nurse and her salary. The aim is also to compare the salary of a nurse with the wages of representatives of other professions and the ratio of the absolute value of labor. The study aims to establish fluctuations in the salary of a nurse from different regions, hospitals, and departments. A review is done on compensatory and incentive payments, their size, and conditions of implementation.

The study uses a practical comparison method – nurses’ salaries are compared based on size. The study was designed to establish how much payments to a nurse on an official wage correspond to the work performed. The variables are fixed monthly payments, the region of residence, the department, and the nurse’s qualification. Data collection is carried out by analyzing official salary statistics, which are further explored compared to the statistics of average wages.

The strengths of this study are the identification of insufficient payment for the increased workload of nurses. It certainly affects the quality of work and leads to a shortage of specialists. The factors influencing the salary of a nurse are highlighted, such as specialization of a particular direction, work experience, category, qualification, and prestige of a medical institution. Due to the high competition in the labor market in this area and the small number of young professionals, the salary level affects the staffing. A correlation has been established between a high level of income and additional requirements for service and patient care.

The article is helpful for this study because it establishes causal relationships that low wages entail. It leads to an increased workload of nurses, a small amount of time devoted to each patient, and a shortage of workers. Due to the acute deficiency of personnel and the lack of decent pay, a significant burden falls on nurses. An extensive range of everyday duties often does not allow the nurse to pay attention to each patient.

The conclusions of this study include the fact that one of the main problems in the medical industry is the low pay of junior medical staff and nurses. The constantly expanding list of job responsibilities of the nursing staff makes it time-consuming to provide high-quality and attentive care for all patients at all stages of treatment. It was concluded that the number of allowances, incentive payments, and even coefficients for processing is set by the hospital management. Thus, the value of the average income of a nurse can vary greatly and often does not correspond to the workload.

The findings can be practically applied in this study; it highlights the cause of nurses receiving incredibly responsible and challenging work with low wages. It was found that orders to increase incomes force hospital management to take extreme measures – staff reduction with the transfer of responsibilities to the remaining doctors. Therefore, they cannot devote the proper amount of time to patients, which is caused by a lack of time resources.

Review of ‘Evaluation of Nursing Workload and Efficiency of Staff Allocation in A Trauma Intensive Care Unit’

Unlike the rest of the articles, this one has a narrower field of research: nurses of a particular department. This study proves how the ratio of the number of nurses and patients can substantially impact the quality of treatment and care in the intensive care unit. It is shown how an increase in the burden on nursing staff increases the harmful risks of patient outcomes. In addition, the issue of improved medical care costs due to repeated hospitalization and financial costs of patients is raised.

This article has the following objectives: to provide convincing evidence that the staffing of nurses in the intensive care unit significantly affects the outcome of patients. Thus, the researchers seek to identify a correlation of the increased possibility of an outbreak of infectious diseases with understaffed nurses. The aim is also to establish the relationship between the monthly frequency of hospital-acquired infections in the department and the ratio of nurses’ working hours.

Such a research method as observation was used – a description of the nurses’ work schedule and progress in the treatment of intensive care patients. The study was designed to establish a link between infections and the number of nurses work hours. Data collection was carried out by studying medical histories and descriptions of nurses’ labour; then, the information was analyzed when it was organized.

The study’s strengths are considered to be the determination of the optimal load on the intensive care unit nurses. It was revealed that a nurse caring for more than two patients at night increases the risk of several postoperative and infectious complications. This study is of particular value, as it shows that intensive care patients have a more negative outcome of complications if there are more than two patients per nurse. It provides recommendations for the optimal ratio of nurses to patients to avoid their infection. In addition, the study showed that an increase in the nurse-patient ratio increases the mortality rate of patients.

As a result of the study, the following conclusions were made: each additional patient added to the workload of a nurse is associated with an increase in hospital mortality. The chances of staying a day longer in the hospital are also increased, which is a major cost factor. Therefore, expanding the number of nurses is more economical, because then the length of stay of patients in the hospital will be shorter and this will help to avoid re-hospitalization.

It is essential to consider the findings in this study since the severity and intensity of the nursing labor process often exceed the norm. Nurses working in the intensive care unit should take care of patients and maintain a specific microbiological state of the environment and the smooth operation of medical equipment. Thus, they face an excessive workload, and, in this regard, the amount of time per patient is reduced.

Review of ‘A Conceptual Framework for Quality of Care’

The article reflects the most significant structural elements of providing medical care to the population at the present stage. The issues of organization and legal regulation of the system of medical care are considered. The medical provision of the people and the quality management system of medical care are described. In addition, the authors analyzed the leading demographic indicators and staffing of the healthcare system.

The purpose of this article is to identify the components of monitoring the quality control of medical care. It aims to obtain information about the state and dynamics of nurses’ work, continuous improvement of their activities, studying the level and trends of professional development. The study should identify external and internal factors on which the success of nursing activities depends. Attention will also be paid to the factors under which the quality of the medical and diagnostic process inevitably decreases in healthcare institutions.

The research method was a generalization – combining the components into one concept of quality nursing care and describing them in a standard system. The study was designed to form an internal environment of a medical organization in which employees are actively involved in patient care. The variables were the policy and action plan in the medical institution, the adopted strategy, and tactics in improving the culture of medical care. Data collection was carried out by studying state documents and local documents of participating hospitals; then, an appropriate concept of quality patient care was formed from the information received.

Among the study’s strengths is the popularization of a quality care policy to increase nursing staff awareness, motivation, and involvement. The article also focuses on implementing processes that allow meeting the requirements of patients and achieving high quality level. The authors recommend hospital management develop, implement and maintain an effective work schedule of nurses to reach quality goals. To involve employees in accomplishing effective care, appropriate working conditions should be created for them.

This article is helpful because it emphasizes that average healthcare professionals form the basis of medical care organizations. It is necessary to determine their needs and expectations from the work schedule, workload, and job satisfaction. It is required to create working conditions that will help ensure the full involvement of employees in the care process and increase work motivation. This is possible only through expanding the number of medical workers and devoting more time to each patient.

The article’s conclusions indicate the need to encourage proactive work behavior and the professional development of employees. It is recommended to achieve this by developing individual and group process management goals and evaluating the results. It is also necessary to investigate the reasons for the arrival of employees in the organization and their dismissal. If the nurse left due to too much workload and the associated inability to provide quality care to all patients, it is necessary to expand the medical staff.

The conclusions obtained in the article are directly related to the topic under study. They confirm that improving the quality of medical processes and services should allow nurses to devote more individual time to each patient. Recovery will be achieved faster and more efficiently when the activities of the nursing staff are carried out in less compressed time resources. System analysis and optimization of processes will increase the labor activity and motivation of medical workers. Therefore, it is advisable to use standard principles and process management methods to achieve quality care without overloading the staff.

Review of ‘Nurse Staffing: The Knowns and Unknowns’

This article was chosen due to the fact that it considers the constant expansion of the nurse’s responsibilities. The most important personality traits of the psyche, which a nurse must necessarily possess, are discussed. Such characteristics of the average medical staff representative as the ability to make decisions independently and quickly respond to changes in the situation in any circumstances are described. The purpose of the article is to establish the direct impact of psychological state on patient survival. The goal was also set to study the burnout syndrome of the average medical staff and the working conditions leading to it. In addition, it was necessary to identify the percentage of nurses leaving the profession because of this phenomenon.

The research method was a conversation and an interview: nurses from different departments answered questions about their psychological state. The study was designed to identify the problems caused by constant overtime work. Data collection was carried out during the interviewing of nurses, and analysis was fulfilled when synthesizing the information received. The study’s strengths are the problem of overtime labor of nurses who regularly work either part-time or overtime. It is proved that fatigue and lack of sleep lead to emotional, social, and cognitive disorders. This reduces the ability of nurses to cooperate with both the doctor and the patient.

The article is relevant for the study, as it also analyzes the level of satisfaction with work among the average medical staff. During the interview, more than half of the employees expressed dissatisfaction with the working conditions and the number of earnings, and the lack of support from management. Professional burnout is associated with these factors, constant processing, emotional exhaustion, and the inability to give each patient the proper amount of time.

The findings obtained by scientists show that working as a nurse is one of the most challenging and harmful to health. Nurses get emotional and physical injuries several times more often than representatives of other professions. The researchers concluded that it is necessary to develop an algorithm of psychological assistance. It is supposed to help nurses maintain mental well-being and not harm themselves even as part of caring for a patient.

The conclusions given in the article are helpful for this study since nurses working under stress are more likely than others to make mistakes when caring for patients. With emotional burnout, cognitive abilities decrease, so the risks become higher when performing manipulations such as working with wounds, injections, and blood sampling. To avoid negative consequences, it is necessary to reduce the workload and the number of patients assigned to one nurse.

Review of ‘The Effect of Reflection on Nurse-patient Communication Skills in Emergency Medical Centers’

This article explores how the treatment of the disease depends on the psychological factor in the interaction of the patient and the medical worker. It is considered what effect the right attitude of the medical worker has on the emergency patient during their contact. This article aims to study the process of communication between a patient and a nurse and to identify factors that may affect the psychological characteristics of their interaction. The study also highlights the attributes of a complex multidimensional process of establishing and developing psychological contacts between people in the emergency medical center.

The research method was the modeling of psychological state in situations when it is necessary to provide urgent medical care. The study was designed considering the essential psychological aspects of nurse-patient interaction. The variables were the degree of deviation from the stable emotional state of the nursing staff and the patient. The study’s strengths were the study of the patterns of interaction between a nurse and an emergency patient from the point of view of medical psychology. The motives and values of the nursing staff, their ideas about the ideal patient, and the patient’s expectations of emergency care were studied in detail. This article was chosen as refereed because it proves the main point of building effective communication in constructing conflict-free communication. At the same time, in conditions of compressed time or overload, the health worker experiences stress, which increases the likelihood of conflicts.

The study’s conclusion confirms that communicative skill is the main professionally significant competence of an average medical worker in an emergency medical center. It is claimed that with a properly structured communication process between a medical worker and a patient, the application process goes much faster. The data given in the article apply to this research, as they link complications, the number of side effects in the emergency medical care with the nurse’s level of stress. It is confirmed that the nurse should not be severely limited in time and be in a state of chronic fatigue. Otherwise, difficulties may occur when forming contact between the participants in the treatment process.

Review of ‘Patients’ Perception of Quality in Healthcare’

This article reflects the assessment by the patient of various models of the relationship between them and the nurse. The factors influencing the patient’s satisfaction with the quality of medical care in a pronounced shortage of resources are identified. The study’s objectives are to determine the most appropriate combination of different types of medical care to the population and to ensure the excellent quality of this care. Special attention is paid to finding ways to effectively solve the problem of ensuring the quality of medical care that meets patients’ expectations in conditions of limited time resources.

Methods such as theoretical analysis and synthesis were used in the article. The study was designed to determine the appropriate volume and quality of medical care that would satisfy patients; the variables were the level of patient satisfaction. Data was collected during the analysis of scientific research, and their analysis was the result of the synthesis of the information received. The study’s strengths include orientation to the data of sociological surveys conducted among patients of different departments. The materials of this study can be effectively used to improve the provision of medical care.

The significance of this study is due to the particular importance of sociological studies of patient’s satisfaction with the quality of medical care provided to them. The study also offers valuable recommendations for improving the subjective assessment of the quality of nursing care. The conclusion given in the study states that it is necessary to take actions to improve the assessment of satisfaction with the quality of medical care in nursing professional activities. The authors also conclude that some of the existing approaches to the definition of quality of medical care require revision. The quality and efficiency problems of nursing work are among the most related to this research, as they are directly related to the limited time and human resources. Achieving an adequate distribution of nursing workload and time devoted to patients is one of the priorities for ensuring the proper provision of nursing services.

Review of ‘The Effects of Nurse to Patient Ratios’

This article is devoted to the requirements for the formation of the ratio of nurses and patients in the organization of the activities of medical organizations. The primary tool for solving this difficult task was the rationing of the work of medical workers. This article aims to determine the ratio of nursing staff and patients to provide high-quality and effective medical services. The report is also aimed at identifying criteria for the rational distribution and use of medical personnel.

The theoretical research methods used in this article are comparison and analysis. The study was designed to calculate the workload standards of medical workers providing primary specialized health care in outpatient settings. The ratio of nurses to patients was variable; data collection was carried out by studying data from scientific sources. The study’s strengths are a qualitative comparison of the average time spent on a separate technological operation, taking into account the actual repeatability coefficient of the process. The optimal ratio of nurses and patients was calculated, in which it is possible to maximize labor productivity and improve the effectiveness of the activities of the average medical staff.

This article is helpful because it provides practical methods for rationalizing working hours in a medical organization by regulating the nurse-patient ratio. Thus, the optimal distribution of the total temporary work cycle is achieved, and a time space is allocated for each of the patients. The conclusions of this study confirm the existence of the need for a local objective survey of the working hours of average medical workers. For its distribution and practical use, it is necessary to establish a ratio of patients and nurses. The findings can be used in this research when studying the distribution of working hours of nurses. Based on the data on the reasonable time spent by medical personnel, it is possible to determine the most optimal ratio of nurses and patients in a specific hospital.

Review of ‘Patients’ and Nurses’ Perceptions of Quality Nursing Activities’

This article examines the development of a patient-oriented approach and the correspondence of nursing activities to it. The assessment is carried out based on orientation to the patient’s interests, needs, values, and openness and involvement in the decision-making process regarding the provision of medical care. In the long term, high-quality nursing care leads to increased patient compliance and the implementation of continuity of treatment. In addition, patients desire to seek help again from the medical organization in which the patient-oriented approach is implemented. Thus, the favorable impact of high-quality nursing services on the financial condition of this medical organization is also evaluated.

The study aims to identify potential vectors of development in the direction of a patient-oriented approach. The quality of medical care is also assessed using an indicator demonstrating the degree of implementation of the patient-oriented method. This indicator is the level of satisfaction with the quality of medical care, reflecting the degree of compliance with the patient’s expectations, interests, and needs. In addition, the indicator reflects the nurses’ ideas about how a medical organization should function. Due to the widespread implementation of the measurement of this parameter, it becomes possible to realize the optimal development of medical organizations in areas relevant to the population.

The research method used in this article is a survey and questionnaire of nurses and their patients, followed by a mathematical analysis of the obtained indicators. The study was designed to conduct comparative research on the main criteria for satisfaction with the quality of medical care. The authors adhered to a patient-oriented concept, and the level of satisfaction with the medical services provided was used as a variable. Data collection was carried out through a survey of patients and nursing staff; then, the obtained data were generalized into numerical form.

The study’s strengths include a scientifically based assessment of hospital performance through a survey of patients and nurses and the development of methods to improve satisfaction indicators. The questionnaire provided allowed medical institutions to assess and improve the satisfaction of consumers and employees. Most of them contain sections for evaluating individual groups of factors that have an impact on happiness. Among them are also time characteristics, such as waiting for an appointment and the duration of an appointment with a nurse. The respondent is asked to evaluate a factor on a numerical scale. This allows determining the degree of compliance with certain expectations of the patient regarding any element in providing medical care.

The significance of this study is to provide an algorithm to increase satisfaction with the quality of medical care among patients and nursing staff. These measurement tools are based on standardized ones that were upgraded during the study, so the validation score of this measurement is relatively high. It is clarified that the study of the level of satisfaction in each region should be carried out using different methodological approaches (Krisda et al., 2019). Research aimed at developing a tool for determining the level of satisfaction requires a comprehensive approach, which was applied in this study.

The conclusions of this article are the criteria for the proper quality of medical care according to patients and nurses. The methods of determining the conformity of the provided medical care with the modern idea of its necessary level and volume were clarified. At the same time, it turned out to be important to take into account the specific pathology and individual characteristics of the patient and the capabilities of a particular medical institution. It was also possible to determine which medical care patients and nurses consider substandard, and the factors affecting its quality. diseases. At the same time, the assessment of the quality of care depends on the preferences of consumers and nurses. Thus, the concept of quality of medical care and its assessment in modern conditions were defined, based on new approaches and criteria.

The conclusions of the article are applicable to the topic of this study, since time factors influence an adequate assessment of the ultimate benefit of using a particular procedure. From the point of view of the impact of medical services on the quality of later life, the most beneficial effects are those that are performed in conditions of sufficient time and lack of overloading of the nurse. Related to this is also the characteristic of the availability of assistance, which is understood as the possibility for the consumer to receive the necessary assistance at the right time, in a place convenient for him, in sufficient volume and at moderate and acceptable costs.

Review of ‘Nurses’ Time Allocation and Multitasking of Nursing Activities: A Time Motion Study’

This paper examines the use of such a skill as multitasking by nurses and its effect on the distribution of time allocated to patients. The authors suggest that addressing a new task requires the brain to activate information about the rules that should be followed when performing it. The more difficult or unusual the task, the longer this process lasts. Therefore, the results of the use of multitasking in nurses is a high level of workload. This significantly increases the risk of professional burnout and emotional maladaptation in the form of symptoms of depression, anxiety and emotional distress in average medical workers.

The purpose of the study is to calculate the additional time it takes to switch attention from one patient to another, as well as to increase it if a new patient needs more complex interventions. The authors also intend to experimentally determine what is more time-consuming for a nurse: the transition from familiar to unfamiliar patients, or switching in the opposite direction. In addition, the article searches for an opportunity to either partially get away from multitasking, or find factors that will help neutralize the negative consequences of this phenomenon.

The method used in this study was observation: purposeful and systematic perception of medical processes requiring multitasking, the results of which were recorded. The study was designed to find an opportunity to minimize the number of tasks performed by one nurse. The variables were the number of new patients; throughout the study, the authors addressed the concept of multitasking. Data collection was carried out by analyzing the learned data, and their processing was carried out by calculating the net time spent using mathematical analysis formulas.

The strengths of the study are the existence of an algorithm for a clear distribution of nursing responsibilities, the lack of encouragement for the exchange of functions between secondary medical personnel without industrial necessity. The authors also give useful recommendations, including drawing up and following a strict schedule, according to which repetitive actions, if possible, should be implemented at a strictly defined time. It is also indicated that the change of tasks should not be too frequent, and the nurse should be given enough time to pay attention to each patient.

The value of this article for research is that it offers effective ways of competent use of time resources. The authors turn to the time management technique, which will allow both to effectively serve an ever-growing number of patients, and to perform the necessary amount of organizational work, and fill out the required number of administrative documents. To maintain a balance between productivity and rational time allocation, nurses need to learn how to improve efficiency within the limited resource of available time.

The conclusions obtained in the study state that the lack of a competent approach to time management negatively affects all aspects of the nurse’s work. Excessive workload due to multitasking hinders the professional growth of a nurse, hinders the accumulation of experience, slows down career advancement and undermines authority, which ultimately reduces her level of job satisfaction. A study of representatives of nursing staff of various profiles and specializations showed that employees who are forced to constantly resort to multitasking have numerous symptoms of emotional burnout syndrome.

Thus, the results of the article can be used in this study, since they are associated with the reduction of professional responsibilities as a result of limited time resources. The proposed time management in nursing helps nurses organize and prioritize time for patient care, internal administrative tasks, educational goals and personal responsibilities. Additional advantages of applying the principles of time allocation in the work of a nurse are increased efficiency and productivity, and reduced stress levels.

Reference List

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Momennasab, M., Karimi, F., Dehghanrad, F. and Zarshenas, L. (2018) ‘Evaluation of nursing workload and efficiency of staff allocation in a trauma intensive care unit’, Trauma Monthly, 23(1), pp. 1–6.

Mosadeghrad, A. M. (2012) ‘A conceptual framework for quality of care’, Materia Socio Medica, 24(4), pp. 251–261.

Needleman, J. (2015) ‘Nurse staffing: The knowns and unknowns’, Nursing Economics, 33(1), pp. 5–7.

Pangh, B., Jouybari, L., Vakili, M. A., Sanagoo, A. and Torik, A. (2019) ‘The effect of reflection on nurse-patient communication skills in emergency medical centers’, Journal of Caring Sciences, 8(2), pp. 75–81.

Patients’ perception of quality in healthcare (2017), Report of a survey conducted by EPF in 2016, EPF, pp. 1–34. European Patients’ Forum, Belgium.

Patterson, J. (2011) ‘The effects of nurse to patient ratios’, Nursing Times, 107(2), pp. 22–25.

Wichowski, H. C., Kubsch, S. M., Ladwig, J. and Torres, C. (2003) ‘Patients’ and nurses’ perceptions of quality nursing activities’, British Journal of Nursing, 12(19), pp. 1122–1129.

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Creating a Concept Map

The comfort theory first introduced by Katharine Kolcaba in the 1990s is one of the widely recognized middle-range theories in nursing (McEwin & Wills, 2019). It includes several concepts, including the four basic nursing conceptual components: health, person, environment, and health. The framework also introduces concepts unique to the theory – comfort, health care needs, intervening variables, health-seeking behaviors (HSBs), and more (Gray et al., 2017). The connection between these ideas can be shown with the help of concept mapping that places concepts in relation to one another (Veo, 2010). The following concept map outlines the main concepts of the comfort theory and its relational statements.

Problem and Purpose Statement

As can be seen from the concept map, comfort is the central concept of the theory – it is influenced by several variables while also influencing health-seeking behaviors (HSBs) and healthcare organization policies. The relationship between nurses’ comforting interventions and the patients’ comfort is the foundation of the theory. The problem is that patients’ health is influenced by their level of comfort, and nurses need to make decisions to facilitate enhanced comfort. Thus, nursing is defined by assessing patient needs and actions to influence and evaluate patient comfort (Faria et al., 2018). The purpose of the comfort theory is to establish the link between nursing interventions and patients’ comfort.

Relational Statements’ Description

The first group of relational statements is the influence of various factors on the creation and improvement of comfort. First, the health care needs are defined either by the patient or the family influence the level of comfort (McEwin & Wills, 2019). Second, the nurses’ interventions are the actions that nurses take to make sure that the patient is comfortable (McEwin & Wills, 2019). As noted above, they include assessment of the patient’s needs, the selection of an appropriate intervention, and the evaluation of the patient’s comfort level (Berntzen et al., 2020). Finally, the patient’s comfort is also influenced by intervening variables – a set of factors that cannot be controlled or are unlikely to change. Intervening variables may include the patient’s prognosis, their social-economic status, family support, and others.

HSB and comfort are two interlinked concepts that influence one another. On the one hand, Kolcaba poses that the improvement of comfort can lead to patients expressing more desire to enhance their health. As higher comfort reduces the tension the patient experiences due to their health problems, it also creates a better foundation for healing (McEwin & Wills, 2019). On the other hand, it is possible to pose that health-seeking behaviors increase the patients’ ability to experience comfort as they are available for nursing interventions. Finally, the organization’s policies and integrity can positively affect the patients’ HSB. The best policies concept refers to the procedures organizations create based on evidence of best comfort-improving behaviors. Similarly, the financial stability and values of the institution make its integrity. This is the relational statement – best policies and organizational integrity influence patients’ health-seeking behaviors by facilitating comfort improvement.

Conclusion

The middle-range theory of comfort uses the concepts of comfort, nursing interventions, health-seeking behaviors, intervening variables, and others. The central idea is that patients’ comfort is important in their care. Therefore, nurses should develop interventions to improve patient comfort, although other factors can either help or create problems in this process. The theory’s relational statements demonstrate a link between nurses’ behavior, the organization’s environment, and patient outcomes. This ideology can be used in practice for a variety of healthcare problems.

References

Berntzen, H., Bjørk, I. T., Storsveen, A. M., & Wøien, H. (2020). “Please mind the gap”: A secondary analysis of discomfort and comfort in intensive care. Journal of Clinical Nursing, 29(13-14), 2441-2454.

Faria, J. M. S., Pontífice-Sousa, P., & Gomes, M. J. P. (2018). Comfort care of the patient in intensive care – An integrative review. Enfermería Global, (50), 503-514.

Gray, J.R., Grove, S.K., & Sutherland, S. (2017). Burns and Grove’s the practice of nursing research: Appraisal, synthesis, and generation of evidence (8th ed.). Saunders Elsevier.

McEwin, M., & Wills, E. M. (2019). Theoretical basis for nursing (5th ed.) Wolters Kluwer Health.

Veo, P. (2010). Concept mapping for applying theory to nursing practice. Journal for Nurses in Staff Development, 26(1), 17-22.

Intensive Care Units are often susceptible to danger, risky procedures, or mismanagement of care. As such, it is essential to establish clear and traceable care quality indicators which will allow hospital staff to react accordingly. Additionally, it will benefit medical boards in planning better care programs and solutions to risk-high environments within medical facilities. Some of these care quality indicators include rates of unplanned extubations within specific hospitals as well as on a national scale.

The rate of unplanned extubations within Intensive Care Units is an evident indicator of the safety and care of a healthcare organization. Unplanned extubations, or UEs, are classified as accidental or self-extubation. Cases of accidental extubation refer to patients experiencing involuntarily-induced effects during nursing care or medical procedure. In the current research, a definite rate has not been found, as incidences vary from 0.3% to 35.8% in different studies (Lucchini, 2018). Self-extubation occurs when the patient disrupts the medical procedure themselves.

ICUs are settings with a likely high risk of danger and familiarity with potential harm in relation to patients. Much of the negative effects may stem from interference with the provided treatment such as self-removed support or monitoring equipment on a varied scale of invasiveness. Such actions can sway the medical consequences, each with its own severity and danger to the patient’s wellbeing. As such, a substantial portion of the care’s quality is indicated by incidences of positive or negative outcomes. Patients are not the only group affected by possible mishaps, as nurses are often the ones that bear significant responsibility. Some of their tasks include managing and protecting the patients from injury and maintaining the integrity of hospital equipment and devices. In cases of unplanned extubation, a part of the concern is also focused on preserving the quality of endotracheal tubes. Thus, in the cases of unplanned extubation, both self and accidental, the quality of care is observed through the nurse’s ability to react according to an incidence, with emphasis on the patient’s safety and the preservation of life-saving equipment.

Further, other quality care indicators regarding UEs focus on the clear relation between accidental or self-extubation and increased nosocomial pneumonia, increased reintubation, and, in some cases, even death. As accidental extubations are often the results of errors that happen during a patient’s change in position, or tracheal tube conduct and placement, the nursing staff are often responsible for incidents. At the same time, self-extubation may be caused by lacking surveillance, or failure to notice signs of the patient’s readiness to be weaned off mechanical ventilation, or total removal. However, in most studies, it has been noticed that self-extubations are the most common with 50% to a 100% of ICU unplanned extubations being self-caused (Nair, 2017). There are also a number of qualitative data that reveal risk factors that impact nurses and other hospital staff. These include the absence or unavailability of physical restraints, a nurse-patient ratio of 1-to-3, excursions outside of the ICU, insufficient sedation, bedside radiography, and the effects of the night shift on hospital staff as well as the patients.

It has been assessed that nosocomial infections are a common obstacle during hospital or ICU stays. The lungs are the site of the most frequent infections among patients with sepsis. The mortality rate in relation to ventilator-acquired pneumonia (VAP) was concluded to be between 24% and 50%, though some settings had reached a very worrying 78% (Nair, 2017). Nosocomial infections can be prevented, and measure taken to do it can reflect on the quality indicator of VAP rates.

Cases of VAP as quality indicators currently affect hospital staff, including leaders or authorities of medical facilities, by urging them to improve the overall quality and lower costs. This can be seen in certain efforts, such as the Joint Commission’s proposal to compel hospitals to meet certain patient safety goals before receiving accreditation.

Other advised methods of monitoring the quality of care through VAP rates include setting and meeting general benchmarks. Benchmarking is not new to private sectors and businesses but is an emerging tactic within the medical field. In the case of measuring VAP rates, it would be essential to ascertain and analyze risk factors, the comparison of preventative measures, contrast differing clinical or microbiological processes, the comparison of true incidence rates, analysis of procedures, treatments, and selected antibiotics, and the result and consequence of each administered option. Additionally, quality can be monitored through enhanced surveillance systems and technology, the activity of administrative support, the assistance and motivation provided to the healthcare staff, and reactions and assessments from the public or media.

Though the indicators above may establish a clear image of the quality of care in certain establishments, not all of them are as measurable or reliable as quality indicators are expected to be. One definition of quality indicators summarizes them as information that identifies levels of adherence to a specific, standardized target in a way that is simple, confirmed, reliable, and can be reproduced in a hospital setting. In the case of VAP, the patients are affected through their hospital stay and the severity of their infection, and the outcome of it. The working staff is affected when VAP rates are measured as quality indicators throughout the process of the patient’s medical care. For instance, the staff can be assessed on their ability to comply with guidelines, and capability to recommend methods of prevention, diagnosis, and treatment for VAP. Further, the quality indicator can be as specific as possible and in the case of VAP, this can mean that the staff must be equipped to accurately isolate methicillin-resistant Staphylococcus aureus carriers, and administer elective intubation with correct timing, perform adequate sedatives, and monitor the modalities of ventilation. National organizations such as the National Quality Forum also hold stakes in the assessment of quality and cite result measures such as trend identification, effective mitigation models, operations, and positive financial indicators such as reduced bed days in the ICU cost cuts to patients, payers, and hospital expenses.

The length of stay is another factor in determining the quality of care within an ICU. The length of a patient’s stay is determined by a variety of factors that may not always pertain to the quality of care within medical facilities. However, there have been indications of negatively-skewed care quality found in relation to lacking numbers of ICU beds, unavailability of fellows or specialists in training, full-time ICU nurses or practitioners, and recurring 100% bed occupancy (Verburg, 2021). As such, a shift of any of the previous indicators does not only affect the care the patient receives and the staff provides but also the additional costs to the establishments in case of mismanagement or need for additional resources.

The analysis of care quality within hospitals through the use of indicators is essential for the growth and improvement within specific facilities and for national or international standards as well. Though unplanned extubation, VAP, and length of stay are only a fragment of the factors that can be used to determine the quality of care, they are vital and should be monitored through a reliable and measurable system.

References

Lucchini, A., Bambi, S., Galazzi, A., Elli, S., Negrini, C., Vaccino, S., Triantafillidis, S., Biancardi, A., Cozzari, M., Fumagalli, R., & Foti, G. (2018). Unplanned extubations in general intensive care unit: A nine-year retrospective analysis. Acta Biomed, 89(7-S), 25-31. Web.

Nair, N., B., & Niederman, M., S. (2017). Using ventilator-associated pneumonia rates as a health care quality indicator: A contentious concept. Seminars in Respiratory and Critical Care Medicine, 38(3), 237-244. Web.

Verburg, I. M. W., Holman, R., Dongelmans, D., Jonge, E., & de Keizer, N. (2018). Is the patient length of stay associated with intensive care unit characteristics? Journal of Critical Care, 43, 114-121. Web.

Summary

The intensive care unit is a critical department in medical partitioning. It requires health service providers to be competent, committed, and experienced in handling patients in critical conditions. To ensure that the health institutions achieve perfect ICU care, the human resource office, in conjunction with supervisory departments, finds skilled personnel working in those delicate areas. The purpose of this paper is to outline methods for analyzing the ICU job, drafting the job description, and future changes that may affect the future of the job description.

Methods for Conducting Analysis of the Job

The interview is one of the best methods that health institutions can apply to assess the knowledge interviewees have on specific tasks. In this case, the intensive care unit requires nurses to have technical ICU nursing skills such as monitoring the critical patient’s neurological status, offering ventilatory services, administration of medicine, and many more (Hines, 2019). The other quality that the supervisor will check while interviewing potential ICU nurses is the passion for this job. ICU care is demanding and requires nurses to withstand challenging situations in the unit (Li & Pan, 2020). A nurse should be able to withstand seeing patients suffering in the hospital bed, and that is the opportune moment they should offer support to the patient. Additionally, the nurses should have the ability and skill to evaluate dynamic situations. The reason is that patients who are in ICU beds may keep on deteriorating where the matter should be between life and death.

Another method to analyze the job is by carrying it out in the context first to receive first-hand information and experience. By performing the job, the hospital management should take the duties to assess the potential physical hazards based on the ICU care (Li & Pan, 2020). When the team is aware of the unit’s prevailing conditions, they are in a better situation to know what qualifications of nurses they must hire.

Job Description and Specification

1. The ICU nurse is responsible for closely monitoring critical patients by observing the specific procedures and prescribed drugs or therapy for all underlying conditions of the patient.
2. The nurses are responsible for helping the doctors provide physical assessments and administration of treatment for ICU patients.
3. Another duty for the nurses in the ICU department is to monitor unique and important signs and make sure functions for the feeding tubes, ventilators, and other equipment are connected to support the life of a patient in critical condition.
4. An ICU nurse has the responsibility of attending to the patient’s general demands, like bathing them, feeding, and dressing them (Bryant & Parker, 2020). Additionally, on this matter, they are tasked with making the patient comfortable by dressing replacement and taking medicine.
5. Together with other ICU specialists, the nursing practitioner is supposed to work effectively and efficiently to provide clear directions and other procedures in the unit.
6. Another important task is that an ICU nurse is supposed to provide support and education to the ICU patient’s family. That can be achieved by giving responses to the members’ inquiries and offering vital instructions on how they can care for their members.
7. Educational requirements must be fulfilled fully, which means an ICU nurse should be a registered professional nurse. An ICU nurse is supposed to be experienced in nursing and assessed successfully in the internship process.
8. Knowledge and skills requirements for the job should be able to handle a critical and challenging situation with ease and competency (Bryant & Parker, 2020). That includes the ability to decide intelligently in performing their duties and assisting the doctors in the critical department’s operational life.

Future Changes That May Affect the ICU Nursing Job Description and Specification

Critical care is facing some potential obstacles, especially in the future shaped by the problems such as the aging population and the shrinking field of critical care practitioners. The other major factors that affect ICU care’s future are the changes in technology and innovation made in the medical field. For example, many baby boomers are gradually aging, which means the demand for critical care facilities in health institutions will rise (Hines, 2019). The other factor is the experts in the critical care units because the population is highly trained due to research institutes that have good quality equipment in place.

There is current advancement in networking about technology that is likely to redefine the organizational circle of the ICU department. That means in the years to come, care units are possibly having regular relies on resources that range from human and technological approaches (Hines, 2019). Additionally, remote monitoring is helping in leveraging the current workforce, for example, in electronic ICUs, commonly referred to as ICUs. The electronic ICUs allow a nurse to manage all the patients from off-site. From the report, it is anticipated that the ICU department is likely to have changed in the future based on the demographics such as the aging population and the other change will be based on technology and innovation.

References

Bryant, S., & Parker, K. (2020). Participation in a nurse practitioner fellowship to instill greater confidence, job satisfaction, and increased job retention. Journal of The American Association of Nurse Practitioners, 32(10), 645-651.

Hines, K. (2019). Empowering remote nurses with tertiary training – St George – Broken Hill ICU Partnership.Australian Critical Care, 32, S14.

Li, M., & Pan, Y. (2020). ICU nurses’ knowledge, attitude, and behavior about ICU acquired weakness.Journal of Nursing Education and Practice, 10(5), 65-71.

The diagram above analyzes the root causes of the low work morale of nurses working in the intensive care unit (ICU) at the hospital where I am employed. It shows six main reasons underlying nurses’ low morale: inadequate materials and equipment, poor HR management, poor practices, unhealthy workplace environment, poor ICU organization, and inadequate policies. Each of these causes contains several details that explain what constitutes a particular cause.

The first cause leading to nurses’ low work morale is inadequate materials and equipment. According to the diagram, this cause includes such factors as poor inventory management, a lack of personal protective equipment, and the absence of a plan for dealing with equipment failure. Each of these factors affects nurses’ morale by increasing their work stress. They experience moral distress when they lack the essential drugs for treating critically ill patients, cannot protect themselves from becoming infected or do not know what to do when the equipment malfunctions. The second cause is a more global one – inadequate policies at the country’s level. For example, currently, only eight states require hospitals to report their nursing staffing levels (de Cordova et al., 2019). Further, nurses’ licenses confine them to the state that issued their licenses, and nursing practitioners have a limited scope of practice despite their advanced knowledge. All these policies contribute to the problem of a nursing shortage, which, in its turn, exerts pressure on nurses, decreasing their work morale.

The third cause of nurses’ low morale is poor human resource management, comprising six elements. Among them, understaffing and heavy workloads result in significant nurses’ stress as they have to work long hours to provide care to the number of patients that exceeds the required nursing-patient ratio. These factors also lead nurses to perceive their compensation as inadequate, which, coupled with limited career development opportunities, may result in turnover intentions. A lack of digital skills training prevents nurses from effectively operating complicated ICU equipment, and insufficient management support may decrease nurses’ commitment to the profession. The fourth cause is the poor organization of the ICU. As is seen from the diagram, the ICU in this hospital lacks several significant guidelines, protocols, and procedures. It leads to an increased degree of uncertainty in the nursing practice. With not knowing what their organization expects them to do under certain circumstances, nurses become dissatisfied with their job.

The fifth cause is an unhealthy workplace environment, which includes both physical and psychological dimensions. In particular, there are cases of bullying and a lack of managers’ response to reported bullying incidents, which negatively affect the work morale of the victims of bullying. Further, a lack of welfare and recreational facilities and inflexible schedules negatively affect nurses’ morale by preventing them from reaching the right work-life balance.

Finally, the sixth cause is poor practices that are common in the ICU in this hospital. One important practice affecting nurses’ morale is continuing to provide care to hopelessly ill patients upon their relatives’ request. Nurses perceive such care as futile, which results in their moral distress and requires psychological interventions to help them cope with such situations (Asayesh et al., 2018). Inappropriate timing for training sessions means that nurses are asked to attend training while they are providing care to critically ill patients. It leads to their dissatisfaction because they have to skip the training as caring for the patient is more important. Further, physicians’ lack of trust in nurses’ skills undermines nurses’ professional identity, which also leads to decreased work morale. While each cause has to be addressed to increase nurses’ morale, poor practices seem to be changed more easily because they require interventions at the hospital’s management level.

References

Asayesh, H., Mosavi, M., Abdi, M., Masoud, M. P., & Jodaki, K. (2018). The relationship between futile care perception and moral distress among intensive care unit nurses. Journal of Medical Ethics and History of Medicine, 11, 2.

de Cordova, P. B., Pogorzelska-Maziarz, M., Eckenhoff, M. E., & McHugh, M. D. (2019). Public reporting of nurse staffing in the United States.Journal of Nursing Regulation, 10(3), 14–20. Web.

Introduction

Nursing is a profession that is responsible for providing essential health care services to patients. This enables the sick to deal with, cope, and live with illnesses to lead everyday lives. The intensive care unit in a health institution provides life support and critical care for acutely injured patients. The nurses play critical roles in the ICU by monitoring patients’ progress, administering treatments, and maintaining patients’ records. Additionally, they identify changes in patients’ conditions and act immediately. This article summarizes the nursing workflow in the intensive care unit among the enlisted nurses in research conducted in mainland China.

Reasons for Choosing the Article

Firstly, this article was chosen because it provides knowledge in the nursing workflow. This information is helpful in human allocation and nursing management. Allocation involves the reassigning of nursing staff on a day-to-day basis. An account of staff insufficiency, time fluctuations in patient’s requirements, and staff absence is taken. Management in nursing requires the assignment of nurses to various patients. By doing this, the patients’ needs are given the needed attention. Nurse Managers play the overall role of supervising the nursing staff in a hospital.

There was ethical consideration taken into consideration during the research. This was done after the approval of the ethics committee of Xuanwu Hospital in Capital Medical University. The targeted population was informed of the research, and they were given freedom of determination of the research if it made them unsafe and insecure. The design method applied during the research was observational, time, motion, and perspective. It allows the researcher to watch an individual continuously and record their conduct. The time taken by a person to complete each behavior from a start to the end is noted. One’s different manners are assessed according to direction and flow.

Study Area

The study was conducted in a hospital in China with nine ICUs units. It had 159 beds and 40 patients admitted with various illnesses (Han et al., 2020). The workflow of all the nine ICUs was analyzed. Each ICU was assigned one nurse manager responsible for primary nurse tasks. Information technology has cooperated into the workflow of nurses, where most activities are done by a personal digital assistant and an intensive care information system. The patient’s privacy has been protected by ensuring the systems have strong passwords. The publications review method was adopted to recover data from the China National Knowledge Infrastructure and Wanfang databases to identify nursing activities.

Nursing Activities

Nurses were found to perform both direct and indirect roles in the hospital. Direct care services came from a nurse spending time with the patient’s family. Indirect nursing care refers to preparations done by the nurse before interacting and treating the patient (Chipps et al., 2021). To ensure data reliability, a panel of experts comprising the ICU managers discussed the activities assigned to nurses. This ensures that information given at the end of the research is relevant and authentic. Twenty-seven researchers specializing in nursing acted as observers in data collection (Han et al., 2020). Nursing activities were recorded in paper form, including columns indicating the start and finish times. They recorded 107 groups of nursing activities, 6 categories, and 20 subcategories.

Nursing documentation includes assessment, planning, implementation, and evaluation of care. Data records include the patient’s name, address, age, and next of kin. This information is critical in the diagnosis process in addition to avoiding confusion. Similarly, the health personnel can be able to do follow-up quickly. The communication process in the hospital enables the treatment process to be conducted with ease (Happ, 2021). Good communication skills should be used during the interaction to understand the patient’s experiences and concerns. Positive interaction will make the patients accessible and be able to give out truthful information. Doctor-nurse communication is critical for treating the patient and should be on good terms.

Nurses’ personal affairs in the hospital include free time for eating and relaxing. Following shifts can facilitate this is followed so that patients always have caregivers. Order of activities should be observed to ensure a smooth transition from one task to another. The training was conducted before research to elaborate on the purpose, significance, and research tools. The researchers arrived at the working station 10 minutes before time. One nurse was identified for observation, and 30 nurses on duty were examined 79 times during that research period. The nursing work activities and time were written down for analysis purposes. Grading was done on a grade of 1-9 according to their experience and expertise (Happ, 2021). It was noted that most nurses consume their time in direct care, communication, and documentation activities.

Research Limitations

There were many limitations during the research aimed at studying nurses’ workflow. Firstly, lack of data before coming up with the online databases, hence the need for future comparison to verify existing information. The research was only conducted in one hospital, and no comparison was made with other facilities. There is insufficient time to collect, analyze, and verify data since the calculations are complex and time-consuming. Lastly, the nurses may have changed their behavior during the research, and the data might give a negative impression.

Conclusion

The main objective of the study was to observe and analyze workflow for ICU nurses. It was concluded that most nurses spend plenty of their time in direct care services. Nursing managers play a major role in ensuring time management and smooth flow of activities in the hospital. Patients’ data were kept confidential through the use of electronic records. Patients are able to interact with healthcare givers via online.

References

Chipps, E. M., Joseph, M. L., Alexander, C., Lyman, B., Mcginty, L., Nelson-Brantley, H., Parchment, J., Rivera, R. R., Schultz, M. A., Ward, D. M. & Weaver, S. (2021). Setting the research agenda for nursing administration and leadership science.JONA: The Journal of Nursing Administration, Publish Ahead of Print 51(9), 430-438. Web.

Han, B., Li, Q., Chen, X., & Zhao, G. (2020). Workflow for intensive care unit nurses: A time and motion study. SAGE Open, 10(3), 1-10. Web.

Happ, M. (2021). Giving voice: Nurse-patient communication in the intensive care unit. American Journal of Critical Care, 30(4), 256-265. Web.

Summary

Appropriate administration of sedatives and analgesics in an intensive care unit (ICU) is critical to avoid over-sedation or under-sedation. Monitoring sedation depth helps prevent the effects of overdosing or suboptimal dosing. BIS monitors can measure patient response to sedation based on brain activity signals, but they are not commonly used in ICU settings.

Objectives

The objectives of the innovation project are to measure the present use of BIS in sedation at a specific facility and evaluate patient outcomes for BIS-guided sedation compared to routine clinical assessment.

Method

A limited review of recent studies was performed to obtain evidence for using BIS in ICU. The proposed project will be implemented in an ICU context and will involve a baseline survey of BIS use practices, provider training, Bispectral Index (BIS) guided sedation (treatment), clinical assessment (control), and post-implementation evaluation.

Results

The studies reviewed suggest that BIS can be a useful tool for an objective assessment of sedation levels in ICU patients. Using technology is associated with better clinical and financial outcomes.

Discussion

The need for sedatives is relatively high in ICU settings. Optimal sedation is important to promote recovery, reduce ICU hours, and decrease costs. Research evidence supports the use of BIS for objective assessment of sedation levels to avoid adverse effects of high or low dosage administration. This project will implement BIS monitoring in an ICU to improve patient outcomes and reduce hospital costs.

Problem Statement

Sedatives and analgesics are useful medications for managing pain and anxiety, especially in patients under intensive care. Proper sedation of this population is needed to avoid side effects of overdose or suboptimal dosing. Ensuring optimal sedation is an important clinical goal, but assessing the medication need and level can be challenging. In intensive care units (ICUs), physiological measures are commonly used to ensure correct dose administration and monitor analgesic effects (Bocskai et al., 2020). However, this method is often imprecise; thus, most patients are over-sedated, resulting in a prolonged stay (LoS).

Since its development, Bispectral Index (BIS) has been applied widely in the operating room (OR) for general anesthesia but infrequently in ICU settings. The technology provides objective measurements of a patient’s response to sedatives or analgesics based on brain electrical activity. Thus, BIS data can help monitor sedation depth to avoid over-sedation. This project proposal evaluates the potential application of BIS in ICU settings for palliative care.

Synthesis of Evidence-based Research

A review of relevant studies will provide evidence for using BIS to assess the appropriate level of sedation in ICU patients. Suboptimal sedation in intensive care can result in pain perception, whereas over-sedation causes aspiration, cardiac complications, and prolonged LoS (Bocskai et al., 2020). Thus, effective monitoring of sedation depth is critical for optimal patient outcomes. BIS has been established as an effective alternative method to Richmond Agitation Sedation Scale (RASS) for monitoring real-time response to dexmedetomidine and midazolam, especially by ICU patients at a high risk of over-sedation (Zheng et al., 2018). The RASS scores showed a statistically significant correlation with BIS data in all patients (r = 0.724, p<0.05) at various time intervals, suggesting that BIS is potentially a valid and reliable substitute for RASS given its additional benefits of non-invasion and objectivity.

BIS monitors could benefit ICU patients through better clinical outcomes and reduced medical costs. Bocskai et al. (2020) found that anesthesia guided by BIS protects patients under postoperative care against delirium and cognitive dysfunction. Using the technology also reduces ICU painful events, morbidity, and LoS compared to not employing BIS. It also improves a patient’s comfort, safety, and postoperative recovery from flexible fiberoptic bronchoscopy (Zheng et al., 2018). Therefore, BIS monitoring of sedation depth has significant clinical and financial benefits.

BIS is also potentially more sensitive to deep sedation than RASS. BIS detected deep sedation that had not been identified by RASS in 84.4% of ventilated ICU patients, with a sensitivity rate of 94% (Wang et al., 2017). Thus, BIS monitors may be a viable alternative to the cumbersome serial RASS assessments, especially in resource-poor critical care units. It can reduce workloads for staff by providing accurate diagnostic data for deep sedation.

The high sensitivity of BIS makes it especially beneficial to ICU patients receiving invasive procedures. It can reduce the period of mechanical ventilation, intubation, and bronchoscopy in critical care units (Yousefi-Banaem et al., 2020). Observational metrics of sedation depth in palliative care patients, such as RASS, may be less accurate than objective methods. Barbato et al. (2017) found that compared to BIS, RASS and the patient comfort scale are blunt scales and may not give accurate measurements of discomfort and sedation. In contrast, BIS uses electroencephalography (EEG) data and can detect distress that may not be determined using observational methods.

However, BIS data may be less useful in cases where deep sedation is not desired or electrical noise interferes with EEG values. The BIS index is useful for monitoring sedation depth in comatose patients. BIS values are a strong predictor of a coma in ICU settings (Zheng et al., 2018). The technology is also useful in monitoring brain activity in comatose patients. BIS is also indicated for pathologies such as brain injury, hemorrhage, and stroke (Zheng et al., 2018). EEG data can show the extent of cognitive impairment for prompt intervention. Therefore, research evidence supports the use of BIS monitors to efficiently assess sedation depth, monitor patient comfort, and diagnose brain pathologies of ICU patients.

Goal and Objectives

The goal of this innovation project is to implement evidence-based BIS-guided sedation in the ICU. Applying BIS in practice can lead to optimal sedation and reduce the risk of over- or under-sedation. Further, this technology can be useful for monitoring the cognitive functioning of comatose patients. The objectives of this project are:

1. Evaluate the efficacy of BIS in assessing discomfort in unconscious patients compared to the RASS scale.
2. Measure the sensitivity of BIS to measure sedation depth in ICU patients compared to the RASS method.

Market/Financial Analysis

Sedation needs of critically ill patients are high, as sedatives improve their tolerance to assisted ventilation. Analgesics and sedatives are indicated for most ICU cases, increasing the financial costs of treatment. Sedation also reduces respiratory complications and infections that increase 30-day readmissions and hospital costs (Yousefi-Banaem et al., 2020). Procedures such as BIS, which ensure optimal sedation, can reduce patient spending on sedatives compared to the subjective RASS technique.

The cost-effectiveness of BIS monitoring is due to reduced drug and hospitalization costs. Setting up and operating BIS monitoring at an ICU can be expensive. A complete BIS monitor costs about $6,500, while the measuring device retails at $25 (Sedation equipment and supplies, 2017). Thus, the acquisition and maintenance of BIS are quite costly. However, the financial benefits of BIS may offset this cost and improve patient outcomes. In particular, the number of sedative drugs needed at ICU will decrease because of BIS-guided optimal titration. Sedation based on BIS monitoring reduced pharmacy costs by 18% or $150 per patient over a period of eight weeks (Shetty et al., 2018). The number of sedatives such as propofol used declined because drug use was optimized. Therefore, direct hospital costs may decline when BIS is used to monitor sedation depth in ICU patients.

The length of ICU stay is generally lower when BIS monitors. Shetty et al. (2018) found that BIS lowered LoS by as much as four days, indicating that this technique improves recovery times in ICU patients. Additional financial benefits come from the reduced risk of over-sedation or under-sedation. At a higher dose, sedatives cause nosocomial infections and delirium (Yousefi-Banaem et al., 2020). The cost of treating these conditions adds a financial burden to patients and families. On the other hand, under-sedation increases patient discomfort and pain. Optimizing sedation to potentially eradicate costly consequences of over-sedation or under-sedation has clear financial benefits.

Proposed Project Plan

Timeline

This project will be implemented in an ICU setting of a hospital providing inpatient procedures. The population of interest will be nurses providing sedatives or analgesics to postoperative patients. A 6-month timeline of activities proposed in this project is presented in Table 1.

Table 1: Project Timeline

Budget

The budget for this project in Table 2 includes the expenditure incurred by the facility for BIS monitors and training costs.

Table 2: Projected Budget

All costs of equipment (BIS monitors, sensors, and electrodes) and installation are by the supplier, SedationKit.com (Sedation equipment and supplies, 2017).

Evaluation/Measurement Plan

Patient Discomfort Measures

An evaluation of the innovation project will determine the success made in achieving the objectives. Patient discomfort or distress will be measured using the Patient Comfort Scale. Scores in clinical measures of comfort range from 0 (full comfort) to 10 (extreme discomfort) (Barbato et al., 2017). This instrument will be evaluated with the Cronbach’s alpha coefficient, and a score of ≥0.7 will be accepted as an indicator of a reliable internal consistency.

Measuring Sedation Depth

EEG data will be used to indicate the sensitivity of BIS to sedation levels. BIS scores range from 100 (conscious) to 0 (unconscious) and thus can be used to indicate the sedative effect of administered drugs (Barbato et al., 2017). The sensitivity of observation measures will be determined using the RASS scale. This tool measures sedation levels ranging from 1 (drowsy) to 5 (unresponsive).

Ethical Implications

The clinical efficacy of BIS for guiding general anesthesia and sedation in ICU settings is established in research. Therefore, patients subjected to routine use (RASS protocol) may be disadvantaged. The LoS, pain level and nosocomial infection rate in this group may be disproportionately higher than in the cohort receiving BIS guided sedation. Additionally, the risk of over-sedation is elevated when subjective sedation assessment methods, such as RASS, are used. Thus, patients may suffer aspiration and long-term cardiac complications that affect their quality of life (Shetty et al., 2018). Under-sedated patients experience pain and discomfort during routine ICU procedures, such as intubation. Nurses have an ethical obligation to alleviate suffering in critical care.

Additionally, measures to reduce harm to the patient are a priority in ICU settings. Thus, the BIS-guided sedation project is aligned with the ethical obligation to reduce patient suffering. The cost of over-sedation to ICU patients and their families is significant. Prolonged LoS, nosocomial infections, and cardiac complications cause an additional burden to individuals and the community. Therefore, from an ethical standpoint, optimizing sedation to reduce LoS and expenditure on drugs is important for hospitals.

References

Barbato, M., Barclay, G., Potter, J., Yeo, W., & Chung, J. (2017). Correlation between observational scales of sedation and comfort and bispectral index scores. Journal of Pain and Symptom Management, 54(2), 186-193.

Bocskai, T., Kovács, M., Szakács, Z., Gede, N., Hegyi, P., Varga, G., Pap, I., Tóth, I., Révész, P., Szanyi, I., Németh, A., Gerlinger, I., Karádi, K., & Lujber, L. (2020). Is the bispectral index monitoring protective against postoperative cognitive decline? A systematic review with meta-analysis. PLoS ONE, 15(2), 1-17.

Sedation equipment and supplies: BIS monitor. (2017).

Shetty, R. M., Bellini, A., Waijayatilake, D. S., Hamilton, M. A., Jain, R., Karanth, S., & Namachivayam, A. (2018). BIS monitoring versus clinical assessment for sedation in mechanically ventilated adults in the intensive care unit and its impact on clinical outcomes and resource utilization. The Cochrane Database of Systematic Reviews, 2018(2), 1-74. Web.

Wang, Z. H., Chen, H., Yang, Y. L., Shi, Z. H., Guo, Q. H., Li, Y.W., Sun, L., Qiao, W., Zhou, G., Yu, R., Yin, K., He, X., Xu, M., Brochard, L. J., & Zhou, J. X. (2017). Bispectral index can reliably detect deep sedation in mechanically ventilated patients. Anesthesia & Analgesia, 125(1), 176–183. Web.

Yousefi-Banaem, H., Goharani, R., Hajiesmaeili, M., Tafrishinejad, A., Zangi, M., Amirdosara, M., & Nashibi, M. (2020). A review of bispectral index utility in neurocritical care patients. Archives of Neuroscience, 7(3), 1-14.

Zheng, J., Gao, Y., Xu, X., Kang, K., Liu, H., Wang, H., & Yu, K. (2018). Correlation of bispectral index and Richmond agitation sedation scale for evaluating sedation depth: A retrospective study. Journal of Thoracic Disease, 10(1), 190-195.