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Background: Medical adhesives are used to affix components to the skin. They are part of procedures performed by medical specialties because of their participation as constituents of different products, such as tapes, dressings, and electrodes. Aim: This study aims to assess the prevalence of, and factors associated with, the development of medical adhesive‐related skin injuries (MARSIs) in patients treated with medical tapes in the neonatology department of a large teaching hospital in Brazil. Study Design: Cohort study. Methods: All premature newborns (gestational age from 28 to <37 weeks) admitted in the neonatal intensive care unit of a teaching hospital, from March to August 2019, were followed up. Neonate skin condition was assessed based on the Neonatal Skin Condition Scale (NSCS). Data analyses were conducted in R software. Results: In total, 46 premature newborns were included in the study; 552 evaluations were performed—mean of 11.7 per patient. Most neonates (n = 41; 89.1%) used adhesive tapes, either paper tape (n = 37; 80.4%) or transparent film dressing (n = 34; 73.9%). Newborns' face and head were the most affected body regions (n = 125; 50.2%). Eight patients had MARSIs (19.5% of patients who used tape). NSCS scores (P value <.001) and the adopted warming system (P value =.01302) were associated with the occurrence of MARSIs. Incubators seem to be a protective factor for MARSI (OR = 0.048; IC95% = 0.0008‐0.75; P value =.013). Conclusion: Adhesive tapes in premature newborns should be considered a risk factor for injuries. Although NSCS showed mild‐to‐moderate impairment and lesion severity was low, this event is relatively frequent in neonatal units. Relevance to Clinical Practice: Awareness of the risk associated with adhesive tape application and removal in newborns allow health services to better address the problem by enforcing good practices, elaborating better protocols, qualifying the health care professionals, and potentially selecting softer tapes for neonates. [ABSTRACT FROM AUTHOR]

Background: Moral distress is recognized as an international problem that contributes to decreased work productivity, job dissatisfaction and intent to leave for adult Critical Care nurses. Aim: To explore Critical Care nurses moral distress levels using the Moral Distress Scale Revised (MDS‐R) and its relationship with intention to stay. The study reported in this paper was part of a larger study that also investigated Critical Care nurses' work environment in Canada and the Midlands region of the UK. Study design: During January to August 2017 a cross‐sectional survey was distributed to adult Critical Care nurses in the Midlands region of the UK. Methods: Surveys were distributed to adult Critical Care Registered Nurses in the Midlands region of the UK examining moral distress levels and intention to stay in Critical Care, the organization (NHS Trust) and in the nursing profession. Results: Two hundred sixty‐six number of a potential sample of 1066 Critical Care nurses completed the survey (25% response rate). Age and moral distress were significantly positively correlated with intention to stay on their current unit (r = 0.16, P =.05), indicating older nurses were more likely to stay in the critical care unit. Moral distress was negatively correlated with intent to stay scores, showing critical care nurses with higher levels of moral distress were less likely to stay on their unit (r = −0.20, P =.02). Moral distress was also significantly negatively correlated with intention to stay with their current employer (r = −0.28, P <.001). Nurses that stated they had high rates of moral distress were more likely to consider leaving their current employer. Conclusion: Moral distress appears to be an issue among adult Critical Care nurses requiring further exploration and development of effective strategies to reduce this phenomenon and stabilize the workforce by reducing turnover. Relevance to clinical practice: By identifying the top causes of moral distress, tools and strategies can be developed to allow the Critical Care nurse to work within an ethically safe clinical environment and reduce the turnover of experienced adult Critical Care nurses. [ABSTRACT FROM AUTHOR]

Background: There is a lack of specific data about the efficacy and safety of medications administered via feeding tubes, although there is a general awareness that not all drug formulations are suitable. Aims and objectives: To overview the current situation with solid medications administered through feeding tubes in the Tartu University Hospital intensive care units. To evaluate the availability of information on the suitability of drug formulations for administration via feeding tubes. Design: This was a descriptive retrospective document analysis study. Methods: During visits to the intensive care units, medication data for current patients were collected from paper medical charts and nurses. In addition, package information leaflets, summaries of product characteristics, and two practical handbooks were used for evaluating the medicines' suitability for administration via feeding tubes. A request for information was also sent to manufacturers or marketing authorization holders. Results: In 3 months, data were collected from 113 intensive care patients' medical charts. A total of 306 medication administrations via feeding tubes were documented and analysed, 67% of which were solid oral dosage forms. Exactly 91.2% of these were conventional tablets. After the analysis of information availability, 88% of the medications were classified as suitable for administration via feeding tubes, but only 48% had the manufacturer‐provided information. Conclusion: This study showed that the information about the suitability of formulations administration through a feeding tube is not readily available for almost half of the medications. The manufacturers seem to have the relevant information, but it is not always added to their medications' official information, putting these patients at higher risk for errors. Relevance to Clinical Practice: This study shows that if there is no clear statement about administration through feeding tubes on official manufacturers' information, this should be sought directly from manufacturers or marketing authorization holders, and the data could be incorporated into local guidelines. [ABSTRACT FROM AUTHOR]

Background: Critically ill patients have the right to communicate and participate in their treatment to avoid adverse medical outcomes due to the severity of their illness, their responsiveness, and level of consciousness. This human right has often been neglected by health care professionals, as a result of limited alternative communication support provided to patients who are unable to speak due to, for example, endotracheal intubation. Despite the successful use of alternative communication strategies in critical care units (CCUs) in other countries, limited implementation in South African hospitals has been reported. Aims and objectives: This study aimed to determine the perspectives of South African nurses working in CCUs on the frequency of use of alternative communication strategies to support patient‐centred communication with critically ill adult patients. Design: The study followed a quantitative non‐experimental survey research design. Methods: A total of 210 nurses working in both private and public hospitals completed a survey on their perspectives on the use of alternative communication strategies in CCUs. Results: Nurse participants reported experience working with critically ill and communication‐vulnerable patients. Nurse–patient communication mainly involved the use of pen and paper, facial expressions and gestures to obtain information relating to patients' needs and their health history. Limited use of speech‐generating communication devices was reported. Conclusion: Nurse training on the use and implementation of alternative communication strategies, such as communication boards or electronic speech‐generating devices, should be investigated to improve nurses' communication with communication‐vulnerable patients in South Africa. Relevance to clinical practice: The results are applicable in clinical practice due to patients' need for alternative communication. The nurses mainly used low‐tech solutions, which are cheap and easy to access. However, there exists an opportunity to increase the use of available digital solutions. [ABSTRACT FROM AUTHOR]

Background: Treatment of paediatric trauma requires specialized infrastructure, medical equipment, medical staff and ancillary support personnel that have been specifically trained for such tasks. Aims and Objectives: To examine the perceptions and attitudes of physicians and nurses in general and paediatric emergency departments (PEDs) on training, confidence, and management of paediatric trauma in order to facilitate the establishment of an optimal model for admitting and treating paediatric trauma patients. Design: Drawing on published literature and a previously conducted qualitative study that explored the provision of medical care to paediatric trauma patients, we conducted an attitude survey. Methods: A 26‐item paper‐based questionnaire was distributed by nurse managers to all staff working within general EDs and PEDs of 22 medical centres across Israel. Results: Of 843 physicians and nurses who completed the survey, 61.1% considered PEDs the most appropriate facility for treating both minor and severe paediatric trauma, 88.5% believed that minor paediatric trauma should be treated in designated paediatric trauma centres, and 53.6% deemed that paediatric emergency medicine specialists are the most suitable primary decision makers in paediatric trauma. PED teams expressed greater professional confidence for treating paediatric trauma and multiple casualty incident patients. Greater professional confidence was positively correlated with paediatric trauma training, greater exposure to paediatric trauma cases, and working in larger medical centres. Conclusions: The results of the current study suggest that PEDs are perceived to be more appropriate for dealing with paediatric trauma. Also, treatment of severe trauma may be more appropriate in centres that admit large numbers of paediatric trauma cases. Relevance to clinical practice: Emergency medicine teams should undergo training for dealing with paediatric trauma. Such training would develop their skills, increase their confidence, and enhance their emotional abilities to cope with paediatric trauma. [ABSTRACT FROM AUTHOR]

Background: Despite technological innovations and continuous improvement in evidence‐based treatments, mortality in the intensive care unit (ICU) remains high. Consequently, a large group of family members may be in need of, and could benefit from, bereavement follow‐up support. Aims and Objectives: To explore the elements, organization, and evaluation of ICU bereavement services in European countries. Specific objectives were to investigate: (a) the model of bereavement follow‐up services (elements of support), (b) the workforce model (organization of staff), and (c) the evaluation model (evaluation strategies). Design: This was a cross‐sectional survey of conference delegates. Methods: A paper‐and‐pen questionnaire, including a cover letter assuring the respondents of anonymity and confidentiality, was distributed to 250 delegates during the opening ceremony of the 2017 European federation of Critical Care Nurses associations Congress in Belfast. The questionnaire was developed from a previously validated tool describing bereavement care practices in ICUs, including questions about the content and organization of bereavement follow‐up services. Frequencies were calculated using yes/no questions, and content analysis was applied in additional free‐text comments. Results: We received 85 responses from publicly employed nurses, mainly in mixed adult ICUs. Respondents were 48 (56.5%) bedside nurses, and the remaining respondents represented clinical nurse specialists, researchers, managers, or academic nurses. Bereavement follow up had existed for about 1 to 15 years. Important follow‐up elements were: viewing the deceased in the unit, 77 (90.6%); providing follow‐up information, 67 (79.8%); sending a letter of sympathy, 17 (20%); and calling the family to arrange a meeting, 27 (31%). Conclusions: Bereavement follow up is common but variable in European ICUs. We recommend the development, implementation, and evaluation of evidence‐based, but culture‐specific, bereavement follow‐up guidelines for European ICUs. Relevance to Clinical Practice: More critical care nurses are realizing the need for bereavement follow‐up guidelines. This paper provides an overview of common elements that might be considered. WHAT IS KNOWN ABOUT THIS TOPICMany families experience the death of a loved one in intensive care unit (ICU).Bereavement services are offered at some ICUs.WHAT THIS PAPER ADDSBereavement services are not systematically offered in European ICUs.Culture‐specific guidelines are needed for bereavement follow up in ICUs.Common elements of bereavement services have been identified, for example, viewing the deceased in the unit, providing follow‐up information, sending a letter of sympathy, and calling the family to arrange a meeting.Consequences of bereavement in ICU have been discussed, for example, prolonged or complicated grief and lack of closure in the bereaved. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to see if a more sophisticated ventilator hyperinflation protocol might result in more sputum clearance compared to manual hyperinflation. Background: Hyperinflation has been used to mobilize lung secretions in mechanically ventilated patients in the intensive care unit setting for almost 50 years. In the past decade, rather than using a bag external to the ventilator circuit to deliver hyperinflation (known as "bagging" or "manual hyperinflation"), a new technique has evolved using existing ventilator circuitry (known as "ventilator hyperinflation"). One conservative ventilator hyperinflation protocol has demonstrated equivalence with manual hyperinflation in sputum clearance. Design A randomized crossover study. Method: Patients received manual hyperinflation and ventilator hyperinflation in two randomly ordered treatments on the same day by the same physiotherapist, using a ventilator hyperinflation protocol involving titration of hyperinflation according to airway pressure. Results: Between 2013 and 2018, 48 patients were enrolled in the study. Physiotherapy treatment using ventilator hyperinflation yielded significantly more wet weight sputum (median 2.84 g, IQR 1.81, 4.22) than treatment using manual hyperinflation (median 1.5 g, IQR 0.73, 2.31, P <.001), without significant differences in secondary measures. Conclusions: A more sophisticated approach to the titration of the volume delivered using ventilator hyperinflation relative to the airway pressure resulted in greater wet weight sputum cleared during physiotherapy treatment. Relevance to Clinical Practice: The results presented in this paper demonstrate that the application of ventilator hyperinflation using peak airway pressure rather than tidal volume may be superior in facilitating sputum clearance and improved oxygenation without patient harm. [ABSTRACT FROM AUTHOR]

Background: Significant barriers can block the provision of palliative care at the end of life in the intensive care unit (ICU). However, the relationship between perceptions of ICU quality palliative care and barriers to palliative care at the end of life is not well documented. Aims and objectives: To describe ICU nurses' perceptions of quality palliative end‐of‐life care, barrier intensity and frequency to palliative care and their association with one another. Design This was a descriptive, correlational, cross‐sectional design. Methods: A convenience sample of 126 ICU nurses from two hospitals in Israel was recruited for the study. Participants completed three pencil‐and‐paper questionnaires (a personal characteristics questionnaire, the Quality of Palliative Care in the ICU and a revised Survey of Oncology Nurses' Perceptions of End‐of‐Life Care). Respondents were recruited during staff meetings or while on duty in the ICU. Ethical approval was obtained for the study from participating hospitals. Results: The item mean score of the quality of palliative end‐of‐life care was 7·5/10 (SD = 1·23). The item mean barrier intensity and frequency scores were 3·05/5 (SD = 0·76) and 3·30/5 (SD = 0·61), respectively. A correlation of r = 0·46, p < 0·001 was found between barrier frequency and intensity and r = −0·19, p = 0·04 between barrier frequency and quality palliative end‐of‐life care. Conclusions: ICU nurses perceived the quality of palliative care at the end of life as moderate despite reports of moderate barrier levels. The frequency of barriers was weakly associated with quality palliative end‐of‐life care. However, barrier intensity did not correlate with quality palliative end‐of‐life care at a statistically significant level. Further research that investigates other factors associated with quality ICU palliative care is recommended. Relevance to clinical practice: Barriers to palliative care are still common in the ICU. Increased training and education are recommended to decrease barriers and improve the quality of ICU palliative care. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Health care associated infections are a major contributor to avoidable harm experienced by patients in modern health care settings. Recent reports suggest that electronic checklists for the documentation of a central line bundle may significantly enhance documented process compliance and help to reduce catheter-related bloodstream infection rates. Aims This paper describes the use of our electronic tool to monitor and feedback process compliance in conjunction of introducing bespoke central line insertion packs to tackle catheter-related bloodstream infections in our intensive care unit in a medium-sized district general hospital. Design and methods Continuous quality improvement programme with 'Plan-Do-Study-Act' cycles was implemented. The central venous catheter insertion and maintenance bundle was rolled out in 2007. To monitor compliance with the bundle elements, an electronic tool was designed as part of our bedside Clinical Information System. From 2009, regular quarterly feedback was provided on the number of central venous catheter lines inserted, compliance with the insertion and maintenance bundle and catheter-related bloodstream infection rate using the data collected through the Clinical Information System. We have also introduced dedicated line insertion trolleys and factory-prepared insertion packs. We used segmented regression analysis to assess the changes in the catheter-related bloodstream infection rate before and after implementation of the central venous catheter bundle. Results Bundle compliance increased during the implementation period and reached over 95% within 6 months. We observed a significant reduction in the catheter-related bloodstream infection rate from 15·6/1000 days to 0·4/1000 days. Regression analysis showed that only the compliance had significant effect on the number and prevalence of catheter-related bloodstream infections. Conclusion/Implications Implementation of evidence-based care bundles reinforced by real-time feedback on the performance of caregivers can significantly reduce the rate of catheter-related bloodstream infection in the intensive care unit. Ensuring that change processes are seamlessly integrated in the workflow with minimal administrative burden is crucial to the quality improvement process. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Patients within the adult intensive care unit have the potential to develop delirium and agitation. This can result in the patient displaying unwanted behaviours such as attempting to remove the medical devices to which they are attached. Some adult intensive care units within the UK are starting to adopt physical restraint as a method of managing unwanted behaviours. Aim To determine the experiences, attitudes and opinions of adult intensive care nurses in relation to the application of physical restraint. Design Questionnaire survey. Methods A postal questionnaire was distributed to all nurses ( n = 192) within two purposefully selected large adult intensive care units in the UK. Results Data were collected between November 2012 and February 2013. The questionnaire was completed by 38·9% ( n = 75) of the nurses contacted. All believed that physical restraint had a place, with the majority of the view that the reason for its application was to maintain patient safety. Some expressed discomfort about the use of physical restraint. Nurses were happy to discuss the use of restraint with families. There was a perceived need for training and support for nursing staff as well as the need for medical staff to support the decision-making process. Conclusion Nurses require more support and evidence to base their decision-making upon. They require guidance from professional bodies as well as support from medical colleagues. The findings have limited generalizability as they can only be applied to the units accessed and the response rate was poor. Relevance to clinical practice Alternative approaches such as pain management, sleep promotion and the involvement of relatives need to be explored before physical restraint policy can be written. Further research is required into the safety of physical restraint, alternative methods of managing the risk of agitation and identifying predisposing factors to accidental device removal. [ABSTRACT FROM AUTHOR]

Background: A significant proportion of hospital deaths occur in intensive care units (ICU) and often follow a decision to limit or withdraw life‐sustaining treatment. Facilitating the preferred choice in place of death for babies/children is increasingly being advocated, although the literature on a home death is often limited to case reports. Aims and objectives: To examine (a) health care professionals' (HCPs) views and experience of transferring babies/children home to die from intensive care, (b) patient clinical characteristics that HCPs would consider transferring home and (c) barriers to transferring home. Design: A cross‐sectional descriptive web‐based survey. Methods: A total of 900 HCPs from paediatric and neonatal ICU across the United Kingdom were invited to participate. Results: A total of 191 (22%) respondents completed the survey; 135 (70.7%) reported being involved in transferring home to die. However, most (58.4%) had just transferred one or two patients in the last 3 years. Overall, respondents held positive views towards transfer, although there was some evidence of divided opinion. Patients identified as unsuitable for transfer included unstable patients (57.6%) and those in need of cardiovascular support (56%). There was statistically significant difference in views between those with and without experience, in that those with experience had more positive views. The most significant barrier was the lack of access to care in the community. Conclusions: HCPs view the concept of transferring critically ill babies/children home to die positively but have infrequent experience. Views held about transfers are influenced by previous experience. The clinical instability of patients and access to community care are central to decision‐making. Relevance to clinical practice: A home death for critically ill babies/children is occurring in the United Kingdom but infrequently. Experience of a transfer home positively influences views and increases confidence. Improved multi‐organizational collaboration between ICU and community care teams would assist decision‐making and facilitation for a transfer home. [ABSTRACT FROM AUTHOR]

Background: Early mobilisation of critically ill adults has been proven effective and is safe and feasible for critically ill children. However, barriers and perceived benefits of paediatric intensive care unit (PICU) staff involvement in mobilising critically ill children are largely unknown. Aim: To explore the barriers and perceived benefits regarding early mobilisation of critically ill children as perceived by PICU staff. Study design: A cross‐sectional survey study among staff from seven PICUs in the Netherlands has been carried out. Results: Two hundred and fifteen of the 641 health care professionals (33.5%) who were invited to complete a questionnaire responded, of whom 159 (75%) were nurses, 40 (19%) physicians, and 14 (6%) physical therapists. Respondents considered early mobilisation potentially beneficial to shorten the duration of mechanical ventilation (86%), improve wake/sleep rhythm (86%) and shorten the length of stay in the PICU (85%). However, staff were reluctant to mobilise patients on extracorporeal membrane oxygenation (ECMO) (63%), and patients with traumatic brain injury (49%). Perceived barriers to early mobilisation were hemodynamic instability (78%), risk of dislocation of lines/tubes (74%), and level of sedation (62%). In total, 40.3% of PICU nurses stated that physical therapists provided enough support in their PICU, but 84.6% of the physical therapists believed support was sufficient. Conclusion: Participating PICU staff considered early mobilisation as potentially beneficial in improving patient outcomes, although barriers were noted in certain patient groups. Relevance to clinical practice: We identified barriers to early mobilisation which should be addressed in implementation research projects in order to make early mobilisation in critically ill children work. [ABSTRACT FROM AUTHOR]

Background: Immobility during hospital stay is associated with muscle weakness, delirium, and delayed neurocognitive recovery. Early mobilisation of critically ill adults improves their physical functioning and shortens the duration of mechanical ventilation. However, comparable research in children is lacking. Aims: To determine the effects of the implementation of an early mobilisation (EM) program on mobility activities for critically ill children and to explore barriers and facilitators and clinical outcomes before and after implementation. Study design: A prospective single‐centre before‐and‐after study. This study was conducted in a PICU of a large tertiary hospital. Children aged from 3 months to 18 years, with an expected stay of ≥3 days were eligible to participate. In the "before" phase, participants received usual care; in the "after" phase we implemented a multicomponent, multidisciplinary EM protocol. The primary outcome was a change in the process outcome "mobilisation activities". Secondary outcomes were PICU staff opinions on mobilisation (survey), safety, process measures, involvement of parents and physical therapist, and clinical outcomes (sedative use and prevalence of delirium). Results: A total of 113 children were included; 55 before and 58 after, with a median age of 31 months (IQR: 10–103) and 35 months (IQR: 7–152), respectively. The number of mobilisation activities (per patient per day) had significantly increased from 5 (IQR: 2–7) to 6 (IQR: 4–8) (U = 272185.0; p <.001). PT consultations for mobilisation had significantly increased from 23.6% (13/55) to 46.5% (27/58) (X2 = 6.48; p =.011). In both phases, no mobilisation‐related adverse events were documented. The survey showed that PICU staff found EM of critically ill children useful and feasible. In the after phase, PICU staff rated the perceived benefit of the support of the physical therapist during mobilisation activities significantly higher than in the before phase (X2 = 34.80; p <.001). Conclusions: Implementation of a structured EM program for critically ill children is feasible and safe. Relevance to clinical practice: It is suggested to start the implementation of a structed EM program with the idendentification of local barriers and facilitators by an interdisciplinary PICU team. Further, an increased presence of physiotherapists on the PICU would improve mobilisation levels, and facilitate mobilisation in critically ill children. Also, they can support and advice PICU nurses and parents in mobilising children. [ABSTRACT FROM AUTHOR]

Background: EM has been hypothesized to help prevent the development of ICU acquired weakness and may therefore result in positive outcomes for ICU patients. Aim: To establish the impact of Early mobilisation (EM) on adult Intensive Care Unit (ICU) patients in terms of ICU length of stay (LOS), as well as hospital LOS, duration of mechanical ventilation, mortality, and functional independence. Study design: A Systematic Review. EMBASE, MEDLINE, CINAHL, and the Cochrane Library were searched on 24th November 2020. Included studies and other systematic reviews were hand‐searched for further includable studies. The primary outcome was ICU LOS whilst secondary outcomes were duration of MV, mortality, hospital LOS and functional independence. The PRISMA guidelines were utilized to perform the review. Ten randomized controlled trials with a combined total of 1291 patients met inclusion criteria and were scrutinized using the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews. Revman 5.4.1 was used to conduct meta‐analysis were possible. Results: Results were limited by the evidence available for inclusion, in particular small sample sizes. However, a trend towards a shorter duration of ICU LOS and duration of mechanical ventilation emerged. There was also a trend towards higher rates of functional independence for intervention groups. Mortality rates appeared unaffected and results of meta‐analysis were statistically non‐significant (p = 0.90). Conclusion: By applying a stricter time limit than previous systematic reviews a trend emerged that the commencement of EM has a positive effect on patient outcomes, in particular ICU LOS. Relevance to clinical practice: The evidence base surrounding EM remains poor; however on the balance of the available evidence the application of EM should not be delayed. [ABSTRACT FROM AUTHOR]

Background: As survivorship following critical illness improves, there is greater focus on maximizing recovery. As well as physical effects, critical illness often results in cognitive impairments such as delirium, anxiety, or disorientation. In other populations, such as delirium, non‐pharmacological approaches to manage these conditions are preferred, including re‐orientation and ensuring personal care needs are met. Cognitive rehabilitation is also well documented for patients with neuropsychological deficits. Treatments include memory aids, compensation strategies, and functional execution. In other hospital populations, games and activities have been utilized to optimize patient engagement, stimulation, and aid recovery, but it is considered an emerging therapy in intensive care. Aims: This service evaluation aimed to gather multidisciplinary team members' perceptions of the use of games based therapy (GBT) in critical care, including patient engagement and acceptability in clinical practice. Study design: A UK‐based single‐centre qualitative service evaluation. Purposive sampling was used to identify interviewees within an adult intensive care who had experience of using a recently implemented GBT intervention. Qualitative data were collected through semi‐structured interviews, which were recorded and transcribed verbatim. Data were analysed using thematic analysis. Results: Eight staff members across the multidisciplinary team were interviewed. One overarching theme of humanizing health care was identified, with three sub‐themes of enhancing recovery, non‐physical components of care, and bespoke tailoring. In addition, further recommendations for development of the service were summarized. Conclusion: GBT was well received by staff in clinical practice. It was described as a supportive adjunct to traditional care and rehabilitation, enhancing staff‐patient relationships. While it was recognized it may not suit all patients, GBT has the potential to enhance cognitive and physical recovery. [ABSTRACT FROM AUTHOR]

Background: The intensive care unit has a much higher pressure ulcers incidence than general wards. Predicting and eliminating the risk of pressure ulcer development is thus of utmost importance in health care, including clinical nursing practice. Aim: The meta‐analysis aimed to examine the predictive validity of the Jackson–Cubbin Scale. Methods: This study is a systematic literature review and meta‐analysis. Research articles published in periodicals indexed targeted the critical care patients and offered sufficient data(true‐positive, false‐positive, true‐negative and false‐negative results) in the EBSCO, PubMed, Ovid, Web of Science and Cochrane databases, as well as those from two journals indexed in a Chinese database (Wangfang Data and China National Knowledge Infrastructure) were reviewed. Preferred reporting items for systematic reviews and meta‐analyses were used; the internal validity of the diagnostic studies was analysed using Quality Assessment of Diagnostic Accuracy Studies 2. Sensitivity, specificity, positive and negative likelihood ratios were counted by STATA 15.0. Results: Nine diagnostic studies with high methodological quality, involving a total of 7684 patients, were retrieved and assessed. This meta‐analysis showed that the pooled sensitivity, specificity and area under the symmetric summary receiver operating characteristic curve of the Jackson–Cubbin Scale were 0.81 (95% confidence interval [CI], 0.58–0.88), 0.76 (95% CI, 0.51–0.95) and 0.84 (95% CI, 0.81–0.87), respectively. Conclusions: The study suggests that the Jackson–Cubbin Scale has a moderate level of predictive validity. Moreover, Jackson–Cubbin's predictive validity could be increased if it was implemented differently based on the attributes of the research participants. Relevance to Clinical Practice: The Jackson–Cubbin Scale has a moderate level of predictive validity with good sensitivity and specificity for the determination of the risk of PUs in adult ICU patients. Bedside nurses could use the Jackson–Cubbin scale for dailly assesment for ICU patients. [ABSTRACT FROM AUTHOR]

Background: Preterm and full‐term infants are often exposed to painful procedures during their hospitalization and pain management should be implemented. Maternal voice is a kind of non‐pharmacologic pain management strategy. However, the efficacy of maternal voice on painful procedures is unclear. Aims: To evaluate the effects of maternal voice on painful procedures in preterm and full‐term infants. Methods: We conducted a systematic search in PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, EMBASE, CINAHL, Chinese Biomedical Literature Database and ProQuest Dissertation and Theses from inception to March 2022. Review Manager 5.3 was used for data analysis. Random effects model was used for pooling data and the quality of outcomes was assessed by GRADE evidence profiles. Results: A total of 10 studies were included in this systematic review and meta‐analysis with 323 participants in the intervention groups and 325 in the control groups. The results showed that maternal voice could reduce pain levels during and until 10 min after painful procedures compared with routine care (SMD = −0.78, 95%CI [−1.12, −0.44], Z = 4.44, p <.00001; SMD = −0.36, 95%CI [−0.66, −0.06], Z = 2.33, p =.02; SMD = −0.87, 95%CI [−1.40, −0.34], Z = 3.20, p =.001; SMD = −0.94, 95%CI [−1.48, −0.41], Z = 3.44, p =.0006; SMD = −1.30, 95%CI [−1.59, −1.01], Z = 8.76, p <.00001, respectively). Patients in maternal voice group had a lower increase in heart rate during and until 2 min after painful procedures (all p <.05). Oxygen saturation was significantly higher in maternal voice group during and until 4 min after painful procedures (all p <.05). The results revealed that maternal voice showed statistically significant effects in respiratory rate and comfort levels during the painful procedures (all p <.05). Conclusion: This systematic review and meta‐analysis indicated that maternal voice was effective in reducing procedural pain levels. The vital signs of patients in maternal voice group were more stable. Relevance to Clinical Practice: Maternal voice can be used as an effective non‐pharmacologic intervention to alleviate procedural pain for preterm and full‐term infants during their hospitalization. Because the quality of synthesized evidence was 'moderate' to 'very low', larger sample size and high quality studies are warranted. [ABSTRACT FROM AUTHOR]

Background: Central line‐associated bloodstream infections (CLABSI) have been a significant challenge in care, increasing healthcare costs and leading to adverse outcomes, including mortality. Aim: The present study aimed to assess the knowledge of intensive care unit (ICU) nurses on the prevention of CLABSI and the implementation barriers of evidence‐based guidelines in practice. Design: A cross‐sectional study. Methods: Data were collected from adult, paediatric, and neonatal ICU nurses working in seven hospitals in Iran, using census sampling from April to July 2020. Results: A number 209 out of 220 ICU nurses participated in the present study (response rate of 95%). The median score of knowledge of ICU nurses towards the prevention of CLABSI was 3.00 out of 11. 50.72% of ICU nurses had insufficient knowledge. The most critical implementation barriers of evidence‐based guidelines were high workload, shortage of necessary equipment, and lack of CLABSI prevention workshops. Conclusions: Overall, the knowledge of ICU nurses towards the prevention of CLABSI was insufficient. Study findings suggest that the knowledge of ICU nurses may be improved by reducing the workload, increasing the number of nursing staff in the ICU, having an adequate supply of equipment needed to ensure safe practice in the ICU, and providing regular related educational workshops for nurses working in the ICU. Relevance to Clinical Practice: The present study's findings suggest that regular training programs should be developed to improve the knowledge of ICU nurses in the care and prevention of CLABSI. Nursing policymakers and managers need to identify and address implementation barriers of evidence‐based guidelines to improve nursing, such as high workload, shortage of necessary equipment, and lack of CLABSI prevention workshops. [ABSTRACT FROM AUTHOR]

Background: Oral care is one of the fundamental nursing care procedures used to decrease oral colonization, dental plaque, respiratory infections, and patient stay and cost. Aims: This study aimed to identify intensive care unit (ICU) nurses' self‐assessment of oral care frequency, skill competency, documentation, oral care tools, and obstacles to oral care quality. In addition, it proposed exploring associations between nurses' attitudes about the importance of oral care and the priority of other interventions. Study design and setting: A cross‐sectional descriptive study was conducted in two ICUs (trauma and general) in the main teaching hospital in Upper Egypt. Of 105 nurses selected using convenience sampling, 91 completed the questionnaire. Results: About 60.4% of ICU nurses did not attend any oral care training programme, 40.7% reported performing oral care four times per shift in intubated patients, 62.6% reported that their skills needed improvement, 37.4% saw themselves as competent, and 86.8% documented oral care in patients' records. Significant positive correlations were found, indicating that nurses' attitudes towards the importance of oral care showed the same tendency as the priority given to other interventions, such as eye care, bowel care, documentation, hygiene, catheters, feeding, and wound care (correlation coefficient [r] = 0.290, 0.511, 0.333, 0.425, 0.431, 0.345, and 0.337, respectively). Furthermore, a toothbrush (84.6%) was often used, while chlorhexidine was not used (90.1%). The major obstacles to the provision of oral care as perceived by the nurses were the fear of aspiration and life‐threatening interventions (95.6%), inadequate nurse–patient ratios (94.5%), irregular competency evaluations (92.3%), unavailability of oral care guidelines (92.3%), and shortage of time (84.6%). Conclusion: The participating nurses were mindful of the importance and priority of oral care. Many of them did not attend oral care training programmes and considered that their skills needed improvement. Moreover, ICU nurses reported many obstacles hindering oral care quality. Relevance to clinical practice: This research identifies the importance of developing in‐service oral care training programmes to improve ICU nurses' skill competency. High‐quality oral care can be provided by focusing on and overcoming obstacles that hinder nurses' oral care practice. [ABSTRACT FROM AUTHOR]

Background: ICUs follow a restrictive companionship policy, especially after the COVID‐19 outbreak. This strategy often limits the time families spend with patients, hinders their knowledge and skills in caregiving, and the sudden transfer of ICU patients to assist with disease monitoring and daily care can be very stressful for families. It is beneficial to use the transition period of transferring ICU patients to help families adjust to the role of caregiver. Aim: To develop and implement a patient‐ and family‐centered transitional care intervention plan for patients transferred to the ICU. Design: Prospective, pretest and posttest design. Methods: The experimental group received an individualized family‐centered transition plan led by the ICU liaison nurse that included 1) communication with health care professionals; distribution of a transfer booklet; 2) identification of nursing issues and communication with the ward nurse; invitation of family members to participate in the patient's rehabilitation; 3) follow‐up instruction on bedside range of motion exercises; and provision of a patient rehabilitation diary. Patients in the control group received only routine care. Data were collected using the General Information Questionnaire, Family Satisfaction with ICU Patients (FS‐ICU), the Family Relocation Stress Scale (FRSS), and the Stanford Acute Stress Response Questionnaire (SASRQR). Results: After the intervention, the total family satisfaction score of ICU patients in the experimental group was significantly higher than that of the control group (87.18 ± 8.38 vs 78.74 ± 10.63, p<0.001), and the satisfaction with the care and information provided was significantly higher in the experimental group compared to the control group (p < 0.001), with no significant difference between the two groups in terms of satisfaction with decision making (p>0.001). The level of relocation stress of patients' families was significantly lower in the experimental group compared to the control group after the intervention (p < 0.001). And there was no statistically significant difference between the two groups in terms of patients' acute stress disorder scores (p>0.001). Conclusion: The implementation of a family‐involved transition care programme significantly improved the satisfaction of ICU patients' families and reduced the stress of relocation for patients' families. Relevance to clinical practice: Focusing on the transition of ICU patients to ensure continuity of critical care and improve the quality of care for ICU patient transfers can be accomplished through a family‐centered transition care plan led by the ICU liaison nurse. [ABSTRACT FROM AUTHOR]

Background: Intensive care nurses play an important role in the management of critically ill patients including identification of cardiac arrhythmias. Interventions to improve arrhythmia identification can be expensive, time‐consuming, and are not always successful. Aims: This study aimed to explore the effectiveness of using short message service (SMS) messaging to improve intensive care nurses' cardiac arrhythmia interpretation skills. Design: This study was a prospective, two‐group, assessor‐blinded, randomized controlled trial with a pretest‐posttest experimental design. Methods: The study was conducted from February 2020 to February 2021 for the intervention as well as the control group, in a teaching hospital in northwest Turkey. The intervention group was sent the one‐way SMS messages on cardiac arrhythmias via WhatsApp during an 8‐week period, whereas the control group did not receive any intervention. The Cardiac arrhythmias assessment questionnaire (CAAQ) was used to measure outcomes. The data were analysed using ANCOVA and an independent t‐test. Results: A total of 66 intensive care nurses were randomly assigned to either the intervention or the control group. The ANCOVA analysis indicated that ICU nurses who received SMS messages about cardiac arrhythmias two times a week had significantly increased CAAQ scores (P < 0.001) with a large effect size (partial eta‐squared = 0.588). Conclusion: This study concluded that using SMS messages as a training tool has a positive influence on cardiac arrhythmias interpretation skills among ICU nurses. Relevance to clinical practice: Using SMS messages could be an alternative, effective, and innovative approach to improve nurses' clinical practice skills. [ABSTRACT FROM AUTHOR]

Background: The coronavirus disease 2019 (COVID‐19) pandemic has spread globally and caused a major worldwide health crisis. Patients who are affected more seriously by COVID‐19 usually deteriorate rapidly and need further intensive care. Aim: We aimed to assess the performance of the National Early Warning Score 2 (NEWS2) as a risk stratification tool to discriminate newly admitted patients with COVID‐19 at risk of serious events. Design: We conducted a retrospective single‐centre case‐control study on 200 unselected patients consecutively admitted in March 2020 in a public general hospital in Wuhan, China. Methods: The following serious events were considered: mortality, unplanned intensive care unit (ICU) admission, and non‐invasive ventilation treatment. Receiver operating characteristic (ROC) analysis and logistic regression analysis were used to quantify the association between outcomes and NEWS2. Results: There were 12 patients (6.0%) who had serious events, where 7 patients (3.5%) experienced unplanned ICU admissions. The area under the ROC curve (AUROC) and cut‐off of NEWS2 for the composite outcome were 0.83 and 3, respectively. For patients with NEWS2 ≥ 4, the odds of being at risk for serious events was 16.4 (AUROC = 0.74), while for patients with NEWS2 ≥ 7, the odds of being at risk for serious events was 18.2 (AUROC = 0.71). Conclusions: NEWS2 has an appropriate ability to triage newly admitted patients with COVID‐19 into three levels of risk: low risk (NEWS2 = 0‐3), medium risk (NEWS2 = 4‐6), and high risk (NEWS2 ≥ 7). Relevance to clinical practice: Using NEWS2 may help nurses in early identification of at‐risk COVID‐19 patients and clinical nursing decision‐making. Using NEWS2 to triage new patients with COVID‐19 may help nurses provide more appropriate level of care and medical resources allocation for patients safety. [ABSTRACT FROM AUTHOR]

Background: Intensive care is one of the most resource‐intensive forms of care because seriously ill patients are cared for in units with high staffing levels. Studies show that the number of registered nurses (RNs) per patient and nurse education level affects patient outcome. However, there is a lack of studies that consider how nurses/patient ratio with an advanced educational level of specialized nurses in intensive care, affect the intensive care performed in different patient populations. Aim: To investigate if differences in patient characteristics and nurse–patient ratio have an impact on the quality of care. Study Design: This is a retrospective observational study with a review of all patients >15 years receiving care at two general intensive care units with different nurse/patient ratio (unit A, 1:1 nurse/patient ratio and unit B, 0.5:1 nurse/patient ratio). Results: There was no significant difference in the initial severity of illness between the units. However, younger patients, male patients and patients requiring surgery entailed a higher workload and a longer intensive care unit (ICU) stay despite a 1:1 critical care nurse/patient ratio. A small difference, but not significant, with more unplanned re‐intubations occurred at unit A compared with unit B. Conclusion: The differences in the nurse/patient ratio did not reflect a difference in the severity of illness among admitted patients but might be explained by patient characteristics with different needs. Relevance to Clinical Practice: Health care managers should consider not only the number of nurses but also their educational level, specific competencies and skills mix and nursing‐sensitive measures to provide high‐quality ICU care in settings with different patient characteristics. Nursing‐sensitive patient outcomes should be considered in relation to nurse/patient ratio, as important to measure to ensure a high quality of patient care in the ICU. [ABSTRACT FROM AUTHOR]

Background: Since the start of the global COVID‐19 pandemic in 2019, critical care nurses across the world have been working under extreme levels of pressure. Aim: To understand critical care nurses' experiences of and satisfaction with their role in the pandemic response across the United Kingdom (UK). Study Design: A cross‐sectional electronic survey of critical care nurses (n = 339) registered as members of the British Association of Critical Care Nurses. Anonymous quantitative and open‐ended question data were collected in March and April 2021 during the height of the second surge of COVID‐19 in the UK via an online questionnaire. Quantitative data were analysed using descriptive statistics and free text responses were collated and analysed thematically. Results: There was a response rate of 17.5%. Critical care nurses derived great satisfaction from making a difference during this global crisis and greatly valued teamwork and support from senior nurses. However, nurses consistently expressed concern over the quality of safe patient care, which they perceived to be suboptimal due to staff shortages and a dilution of the specialist skill mix. Together with the high volume of patient deaths, critical care nurses reported that these stressors influenced their personalwell‐being. Conclusions: This study provides insights into the key lessons health care leaders must consider when managing the response to the demands and challenges of the ongoing COVID‐19 pandemic. COVID‐19 is unpredictable in its course, and what future variants might mean in terms of transmissibility, severity and resultant pressures to critical care remains unknown. Relevance to Clinical Practice: Future responses to the challenges that critical care faces must consider nurses' experiences and create an environment that engenders supportive teamwork, facilitates excellent nursing practice and effective safe patient care where critical care nursing may thrive. [ABSTRACT FROM AUTHOR]

Background: During the COVID‐19 pandemic, intensive care nurses may experience ethical issues related to fear of transmission, limited resources, and increased workload. Nurses' moral sensitivity and courage may have a role in dealing with these problems. Aim: The purpose of this study was to assess intensive care nurses' moral sensitivity and moral courage during the COVID‐19 pandemic. Design: Descriptive cross‐sectional survey. Methods: A total of 362 nurses working in the intensive care units of pandemic hospitals in Turkey participated in the study between January and March 2021. Data were obtained using a personal information form, the Moral Sensitivity Questionnaire, and the Nurses' Moral Courage Scale. A link to the online data collection tools was sent to the management of participating institutions, who forwarded it to nurses. Reporting followed the CHERRIES guidelines. Results: In this study, the response rate of nurses was 89%. The nurses' total mean moral sensitivity score was 90.70 ± 28.89 and their mean moral courage score was 82.08 ± 13.51. A weak inverse correlation was found between the nurses' moral sensitivity and moral courage scores (r = −.176, p =.001). Total moral sensitivity score differed significantly according to years of Intensive care unit (ICU) experience (p =.007). Total moral courage scores increased significantly with education level (p =.012), years of nursing experience (p =.016), and willingness to work in the ICU (p <.001). Conclusion: The study suggests that nurses working in the intensive care unit during the pandemic had moderate moral sensitivity and high levels of moral courage. Nurses' sociodemographic characteristics and ICU work conditions may affect their moral sensitivity and moral courage. Relevance to Clinical Practice: The results of this study can help guide efforts to improve moral courage and sensitivity and address ethical issues among ICU nurses. [ABSTRACT FROM AUTHOR]

Background: Stress is an integral part of daily work for nurses, especially those who work in intensive care units (ICUs). However, chronic stress can affect nurses' mental and physical well‐being, increasing their risk of burnout and decreasing the quality of care. A higher emotional intelligence (EI) level may be correlated with greater use of effective coping strategies, leading to a reduction of the adverse effects of stress. Aim: This study aimed to examine the relationship between EI and coping strategies among adult ICU nurses in Poland. Study Design: A cross‐sectional survey design was used. Current adult ICU nurses in nine Polish hospitals were invited to participate. The survey instruments used were: the Polish version of the Schutte Self‐Report Emotional Intelligence Test, the Inventory to Measure Coping Strategies with Stress (Brief‐COPE), and a self‐constructed questionnaire. Results: 114/543 (21%) nurses completed the survey. ICU nurses showed an average level of EI (70.2%). The main stress coping strategies were active coping and planning, the rarest being substance use, behavioural disengagement, and denial. For nurses with a higher EI level, the most frequently used strategies included positive reframing (R = 0.43; p <.001), active coping (R = 0.38; p <.001), planning (R = 0.37; p <.001) and religion (R = 0.25; p =.006). Nurses were less likely to utilize strategies of behavioural disengagement (R = –0.32; p =.001) and self‐blame (R = –0.40; p <.001). Conclusions: EI may have an impact on coping strategies, as a higher EI level was correlated with the greater use of effective coping strategies in ICU nurses. Relevance to Clinical Practice: Training in coping with stress and increasing EI may have a positive impact on reducing the risk of burnout in nurses and thus improving the quality of care delivered. [ABSTRACT FROM AUTHOR]

Background: Turnover intention among nurses is high, especially in the emergency department. However, factors that are associated with Chinese emergency department nurses' turnover intention have been scarcely studied. Aims: The present study examined relationships between turnover intention and demographic characteristics, job‐related factors, depressive symptoms, and organizational commitment among emergency department nurses. Study Design: A cross‐sectional study of emergency department nurses was conducted in China between July and August 2018. The questionnaire included demographic characteristics (age, gender, level of education, and self‐rated health status), job‐related factors (qualification title, job seniority, night shifts, and workplace violence), depressive symptoms, organizational commitment, and turnover intention. A hierarchical linear regression model was used to identify factors that are associated with turnover intention among emergency department nurses. Results: A total of 17 582 emergency department nurses participated in the study. The response rate was 68.9%. The findings indicated that poor self‐rated health status (β = 0.25, p <.001), working more than 11 night shifts per month (β = 0.14, p <.01), experiencing workplace violence in the past year (β = 0.08, p <.05), and higher depressive symptom scores (β = 0.07, p <.001) positively correlated with turnover intention. More years of service (β = −0.38, p <.001) and higher organizational commitment scores (β = −0.45, p <.001) negatively correlated with turnover intention. Conclusions: Health status, job seniority, night shift frequency per month, workplace violence, depressive symptoms, and organizational commitment were significantly associated with emergency department nurses' turnover intention. Relevance to Clinical Practice: To reduce turnover intention in the emergency department nurses, hospital administrators and managers should implement measures to improve their physical and mental health, increase organizational commitment, develop staff acceptable shift schedules, and reduce incidences of workplace violence. [ABSTRACT FROM AUTHOR]

Background: Constant exposure of health professionals to the pain and suffering of patients can adversely affect their emotional wellbeing. Aim: The study aimed to investigate the prevalence and the factors affecting the levels of secondary traumatic stress/compassion fatigue (STS/CF), burnout (BO) and compassion satisfaction (CS) of health professionals working in adult and paediatric Intensive Care Units (ICU) as well as in departments treating patients with serious illness in five hospitals in Crete. Study Design: A descriptive cross‐sectional survey with the use of the Professional Quality of Life Scale (ProQOL‐CSF‐R‐IV) questionnaire. Methods: We enrolled medical, nursing and support staff working in the adult and paediatric ICU, emergency, oncology, haematology and neurosurgical departments, haemodialysis unit and operating theatre. Results: 598 health professionals completed the questionnaire (response rate 73.2%). Significantly increased levels of STS/CF were observed in non – ICU as compared to ICU staff (p =.009) females compared to males (p <.001), those who have previously experienced a traumatic event (p <.004), nurses and support staff compared to doctors (p =.007 and p =.028 respectively), and people not working in a department by choice (p <.001). CS was higher for older professionals, personnel subjected to stress reduction techniques (p <.019) and professionals working with children or mixed adults and children population (p =.009). Rolling schedule and bad working conditions negatively affected CS (p =.02, p =.001). Increased BO levels were associated with younger age (p =.029) and showed a positive correlation with STS/CF (r =.356, p <.001). Conclusions: STS/CF is common in health professionals regardless of their profession, working department or hospital level. Non‐ICU staff displayed higher STS/CF levels. Working in a department by choice ameliorates CS, BO and STS/CF. Relevance to Clinical Practice: Health professionals need to be informed about the risks of projecting patients' suffering on themselves. Hospital managers and department heads are responsible to provide appropriate support. [ABSTRACT FROM AUTHOR]

Background: The COVID‐19 pandemic has affected millions and resulted in a considerable strain on healthcare systems around the world. Intensive care units (ICUs) are reported to be affected the most because significant percentage of ICU patients requires respiratory support through mechanical ventilation (MV). Aim: This study aims to examine the staffing levels and compliance with a ventilator care bundle in a single city in Pakistan. Methods: A cross‐sectional survey of 14 ICUs including medical and surgical ICUs was conducted through a self‐structured questionnaire including a standardized ventilator care bundle. We assessed the compliance of ICU staff to ventilator care bundle and calculated the correlation between staffing patterns with compliance to this bundle. Results: The unit response rate was 64% (7/11 hospitals). Across these seven hospitals, there were 14 functional ICUs (7 surgical and 7 medical). The Mean (SD) numbers of beds and ventilators were 8.14 (3.39) and 5.78 (3.68) while the average patient‐to‐nurse and patient‐to‐doctor ratio was 3: 1 and 5:1 respectively. The median ventilator care bundle compliance score was 26 (IQR = 21–28) out of 30, while in medical and surgical ICUs, median scores were 24 (IQR = 19–26) and 28 (IQR = 23–30) respectively. The perceived least compliant component was head elevation in ventilated patients. Correlation analysis revealed that 24 h a day, 7 days a week onsite cover of Advanced Cardiovascular Life Support certified staff was positively correlated with the ventilator care bundle score (rs = 0.654, p value =.011). Similarly, 24‐h cover of senior ICU nurses was significantly correlated with the application of chlorhexidine oral care (rs = 0.676, p value =.008) while routine subglottic aspiration was correlated with the number of doctors (rs = 0.636, p value =.014). Conclusion: Our study suggests that ICUs in Peshawar are not well staffed in comparison with international standards and the compliance of ICUs with the ventilator care bundle is suboptimal. We found only a few aspects of ventilator care bundle compliance were related to nursing and medical staffing levels. Relevance to clinical practice: Critical care staffs at most of the medical ICUs in Peshawar are not compliant with the standard guidelines for patients on mechanical ventilation. Moreover, the staffing levels at these ICUs are not in accordance with international standards. However, this study suggests that staffing levels may not be the only cause of non‐compliance with standard mechanical ventilator guidelines. There is an urgent need to design and implement a program that can enhance and monitor the quality of nursing care provided to mechanically ventilated patients. Lastly, nurse staffing of ICUs in Pakistan must be increased to enable high quality care and more doctors should be trained in critical care. [ABSTRACT FROM AUTHOR]

Background: Employee bullying and burnout are two crucial, prevalent and challenging concepts that adversely affect organizational staff behaviours. Also, adverse patient care is associated with nurse bullying and burnout. Aim: This study aimed to assess the incidence and association between workplace bullying and occupational burnout among nurses in critical care units in Iran. Study design: A cross‐sectional descriptive study. Methods: The subjects were 184 nurses from critical care units in 6 teaching hospitals in Iran. Three questionnaires were distributed among the study population; (a) demographic characteristics questionnaire, (b) Maslach Burnout Inventory (MBI) and (c) bullying at Workplace Questionnaire. Descriptive statistics were used to present the workplace bullying and occupational burnout status among nurses. Linear and logistic regression analyses were conducted to estimate the relationship between workplace bullying with MBI and nurses' demographic characteristics, respectively. Results: 62% of the nurses had moderate emotional exhaustion, 59.8% had moderate depersonalization and 46.2% had a moderate individual achievement. 75.5% faced workplace bullying. There was a positive and significant association between bullying scores and burnout in total (Pearson's r = 0.598, p < 0.001). Linear regression test showed a positive and significant relationship between bullying with MBI dimensions (R = 0.613, p < 0.001) for emotional exhaustion, (R = 0.679, p < 0.001) for depersonalization and (R = −0.417, p < 0.001) for individual achievement. Conclusions: Among Iranian nurses, bullying is a prominent and substantial issue that significantly correlates with their negative performance by enhancing job burnout. Relevance to Clinical Practice: It is suggested that some measures are adopted to avoid workplace bullying and to reduce occupational burnout for nurses. Managers should create an environment that encourages nurses to voice their concerns – informing nurses about their rights and creating a positive atmosphere in the hospital. [ABSTRACT FROM AUTHOR]

Background: Frontline nurses dealing with the coronavirus disease‐2019 (COVID‐19) pandemic face various mental health challenges ranging from excessive stress and anxiety to severe depression. Aims: To study the comparative prevalence of anxiety and depression, and their contributing factors, between nurses working in intensive care units (ICU) with COVID‐19 patients (COVID ICU) and nurses working in ICU with patients admitted for other reasons (non‐COVID ICU). Design: Quantitative comparative cross‐sectional study. Methods: All frontline nurses working in COVID and non‐COVID ICUs at a tertiary care university hospital in Nepal were included. The data were collected using Google Forms. The groups were evaluated and compared in terms of various relevant variables with self‐designed socio‐demographic questionnaire, the validated Nepali version of the Hospital Anxiety and Depression Scale (HADS), and the General Health Questionnaire 12 (GHQ‐12). Results: The response rate was 100%. Of the 99 nurses who met the inclusion criteria, three were excluded. Out of the 96 nurses included, psychiatric caseness was present in 82 (85.4%). There was no statistically significant difference in the prevalence of psychiatric caseness, anxiety, and depression between the COVID ICU and non‐COVID ICU nurses (caseness of 90.4% vs 79.5%, P =.134; anxiety of 36.5% vs 27.3%, P =.587; and depression of 21.2% vs 9.1%, P =.214, respectively). Among the factors that could potentially lead to psychiatric caseness, anxiety, and depression, statistically significant differences were observed only in relation to sleep disturbances, confidence in caring for patients with COVID‐19 and intentions to discontinue current job, all being significantly higher in COVID ICU nurses. Conclusion: Anxiety and depression are common in nurses working in both the COVID and non‐COVID ICUs, although the difference is not statistically significant. Relevance to clinical practice: Early assessment of anxiety and depression in nurses working in all ICUs and their active medical and behavioural interventions are important in protecting this vital work force dealing with the pandemic. [ABSTRACT FROM AUTHOR]

Background: Intensive care settings are characterized by their structure, which constantly changes in parallel with scientific and technological developments, the uncertainty of the lifeline between birth and death, the challenges in the fair distribution of limited resources, the participation of individuals in medical decisions, and witnessing the pain experienced by individuals. These characteristics also affect the level of moral distress, which can make it difficult for ICU nurses to provide the most appropriate individualized care for their patients. Aims: The purpose of this study was to determine the moral distress levels and individualized care perceptions of intensive care nurses. Study design: This study employed a cross‐sectional descriptive survey design. Methods: This descriptive study was conducted with 128 nurses working in the intensive care units of a university hospital in Turkey. Data were collected using an 'Information Form', 'the Moral Distress Scale', and 'the Individualized Care Scale‐Nurse Version'. Results: 78.9% of the nurses stated that there was staff shortage, and 36.0% stated that the physical conditions were not suitable for care in the intensive care units in which they worked. The mean score on the Moral Distress Scale was 79.2 ± 46.4. The mean total score on the Individualized Care Scale‐Nurse Version was 3.5 ± 0.8. Conclusion: This study revealed that the intensive care nurses had moderate levels of moral distress and good levels of individualized care perceptions although there was no significant relationship between their moral distress levels and individualized care perceptions. Also, the nurses adopted care behaviours supporting patients' feelings and autonomy. Relevance to clinical practice: In our study, the intensive care nurses did not reflect their moderate‐level moral distress in the individualized care provided. It could be beneficial to measure intensive care nurses' moral distress and care levels at frequent intervals so that early precautions could be taken to prevent the accumulation of moral distress and care difficulties among intensive care nurses. [ABSTRACT FROM AUTHOR]

Background: The coronavirus disease 2019 (COVID‐19) pandemic directly affects the psychological well‐being of critical care nurses. Several studies had investigated the psychological impact of the pandemic on nurses caring for patients with COVID‐19, but few were conducted to identify the predictors of this impact. Aims: The objective of this study is to identify the predictors of critical care nurses' stress, anxiety, and depression in response to the COVID‐19 pandemic. Design: A cross‐sectional survey was conducted in five intensive care units in five hospitals in Alexandria, Egypt. Methods: An online questionnaire was distributed. It included socio‐demographic and work‐related data and the depression, anxiety, and stress scale scores of the nurses under study. A multiple linear regression model was developed to identify the predictors of critical care nurses' stress, anxiety, and depression in response to the COVID‐19 pandemic. Results: Two hundred (64%) of 308 nurses completed the electronic questionnaire. Significant predictors of stress included the number of infected colleagues (P <.001) and availability of hospital resources (P =.01). Significant predictors of anxiety were age, gender, satisfactory income (P <.001), years of experience, time spent caring for patients with COVID‐19 (P =.04), continuous training, number of infected colleagues (P =.01), and availability of hospital resources (P =.02). Finally, significant predictors of depression included gender, history of physical problems (P =.04), educational attainment, availability of hospital resources, history of psychological problems (P <.001), and number of infected colleagues (P =.001). Conclusion: The hospital's lack of human and physical resources and the number of colleagues infected with COVID‐19 were the strongest predictors of stress, anxiety, and depression among nurses. Relevance to clinical practice: Identifying the predictors of stress, anxiety, and depression among nurses who care for patients with COVID‐19 is a vital step in developing mental health promotion strategies to support nurses during this pandemic. [ABSTRACT FROM AUTHOR]

Background: Recent studies in the Kingdom of Saudi Arabia (KSA) have shown that the increasing nursing turnover in the health care industry has become a great source of concern. The overdependence on the supply of expatriate nurses (74%) and coronavirus disease 2019 (COVID‐19) travel restrictions have exacerbated this staffing issue. Aims: To examine the relationship between perception of nursing practice environment (NPE), job satisfaction and intention to leave (ITL) among critical care nurses working in the state of Ha'il in KSA. Design: Cross‐sectional correlational (observational) design. Methods: Data were collected via electronic online survey distributed to registered critical care nurses working in King Khalid Hospital (KKH), Ha'il, KSA, between July and August 2020. Participant demographics and key variables data related to NPE, job satisfaction and ITL respectively were collected from the participants using existing and validated questionnaires. Descriptive statistics and correlational analysis and multivariable analyses were conducted. Results: A response rate of 98% was achieved (152/160) for the study. Findings showed that the NPE was largely favourable (M = 2.89, SD = 0.44); however, nurse participation in hospital affairs (M = 2.83, SD = 0.47) and staffing and resource adequacy (M = 2.88, SD = 0.47) scored lowest. NPE was found to be significantly correlated with job satisfaction (rs =.287, P <.01). A significant negative relationship was found between NPE and ITL (rs = −0.277**, P <.01). However, job satisfaction was associated with ITL (rs = −.007, P =.930). Conclusions: Maintaining a healthy work environment and job satisfaction levels in critical care units is key to improving, recruitment and retention of nursing staff. Relevance to clinical practice: Critical care and hospital leaders should implement programs that enhance the quality of the practice environment. This will improve nurse participation in unit and hospital affairs, job satisfaction and intention to stay. [ABSTRACT FROM AUTHOR]

Background: During the Coronavirus disease 2019 (COVID‐19) pandemic, hospital visits were suspended and video calls were offered to connect patients with their family members, especially toward the end of life (EoL). Aim: The primary aim was to describe EoL care for COVID‐19 patients dying in an intensive care unit (ICU). The secondary aim was to explore whether making video calls and allowing visits was associated with lower death‐related stress in family members. Design: Single centre cross‐sectional study. The setting was the ICU of a COVID‐19 center in northern Italy, during the first year of the pandemic. Data on patients who died in the ICU were collected; death‐related stress on their family members was measured using the Impact of Event Scale‐Revised (IES‐R). The statistical association was tested by means of logistic regression. Results: The study sample included 70 patients and 56 family members. All patients died with mechanical ventilation, hydration, nutrition, analgesia and sedation ongoing. Resuscitation procedures were performed in 5/70 patients (7.1%). Only 6/56 (10.7%) of the family members interviewed had visited their loved ones in the ICU and 28/56 (50%) had made a video call. EoL video calls were judged useful by 53/56 family members (94.6%) but all (56/56, 100%) wished they could have visited the patient. High‐stress levels were found in 38/56 family members (67.9%), regardless of whether they were allowed ICU access or made a video call. Compared with other degrees of kinship, patients' offspring were less likely to show a positive IES‐R score (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.05 to 0.89). Conclusions: During the first year of the COVID‐19 pandemic, patients died without their family members at the bedside while on life‐sustaining treatment. Stress levels were high in most family members, especially in patients' spouses. Video calls or ICU visits were judged favourably by family members but insufficient to alleviate death‐related stress. Relevance for Clinical Practice: During a pandemic, ICU access by patients' family members should be considered, particularly as the time of death approaches. Although generally appreciated by family members, EoL video calls should be arranged together with other measures to alleviate death‐related stress, especially for the patient's spouse. [ABSTRACT FROM AUTHOR]

Background: A spontaneous breathing trial (SBT) is recommended to help patients to liberate themselves from mechanical ventilation as soon as possible in the ICU. The respiratory workload in SBT, which depends on being with or without respiratory support and a specific time, is more accurate to reflect how much support the weaning patients need compared with only considering SBT technologies. Aim: To compare and rank the effectiveness of different respiratory workloads during SBT via differing technologies (Pressure Support Ventilation and T‐piece) and differing duration (30 and 120 min) in SBTs. Study design: A comprehensive literature search was performed in six English electronic databases to identify eligible randomized controlled trials (RCTs) published before September 2020. The pooled risk ratio (RR) with 95% confidence interval (CI) was calculated by Markov chain Monte Carlo methods. A Bayesian network meta‐analysis was conducted using "gemtc" version 0.8.2 of R software. Each intervention's ranking possibilities were calculated using the surface under the cumulative ranking analysis (SUCRA). Results: A total of nine RCTs including 3115 participants were eligible for this network meta‐analysis involving four different commonly used SBT strategies and four outcomes. The only statistically significant difference was between Pressure Support Ventilation (PSV) 30 min and T‐piece 120 min in the outcome of the rate of success in SBTs (RR = 0.91; 95% CI, 0.84–0.98). The cumulative rank probability showed that the rate of success in SBT from best to worst was PSV 30 min, PSV 120 min, T‐piece 30 min and T‐piece 120 min. PSV 30 min and PSV 120 min are more likely to have a higher rate of extubation (SUCRA values of 82.5% for 30 min PSV, 70.7% for 120 min PSV, 36.4% for T‐piece 30 min, 10.4% for T‐piece 120). Meanwhile, T‐piece 120 min (SUCRA, 62.9%) and PSV 120 min (SUCRA, 60.9%) may result in lower reintubation rates, followed by T‐piece 30 min (SUCRA, 41.8%) and PSV 30 min (SUCRA, 34.4%). Conclusions and relevance to clinical practice: In comprehensive consideration of four outcomes, regarding SBT strategies, 30‐min PSV was superior in simple‐to‐wean patients. Besides, 120‐min T‐piece and 120‐min PSV are more likely to achieve a lower reintubation rate. Thus, the impact of duration is more significant among patients who have a high risk of reintubation. It is still unclear whether the SBTs affect the outcome of mortality; further studies may need to explore the underlying mechanism. [ABSTRACT FROM AUTHOR]

Background: The COVID‐19 pandemic has been associated with an unprecedented number of critical care survivors. Their experiences through illness and recovery are likely to be complex, but little is known about how best to support them. Aim: This study aimed to explore experiences of illness and recovery from the perspective of survivors, their relatives and professionals involved in their care. Study design: In‐depth qualitative interviews were conducted with three stakeholder groups during the first wave of the pandemic. A total of 23 participants (12 professionals, 6 survivors and 5 relatives) were recruited from 5 acute hospitals in England and interviewed by telephone or video call. Data analysis followed the principles of Reflexive Thematic Analysis. Findings: Three themes were generated from their interview data: (1) Deteriorating fast—a downhill journey from symptom onset to critical care; (2) Facing a new virus in a hospital—a remote place; and (3) Returning home as a survivor, maintaining normality and recovering slowly. Conclusions: Our findings highlight challenges in accessing care and communication between patients, hospital staff and relatives. Following hospital discharge, patients adopted a reframed 'survivor identity' to cope with their experience of illness and slow recovery process. The concept of survivorship in this patient group may be beneficial to promote and explore further. Relevance to clinical practice: All efforts should be made to continue to improve communication between patients, relatives and health professionals during critical care admissions, particularly while hospital visits are restricted. Adapting to life after critical illness may be more challenging while health services are restricted by the impacts of the pandemic. It may be beneficial to promote the concept of survivorship, following admission to critical care due to severe COVID‐19. [ABSTRACT FROM AUTHOR]

Background: Unplanned extubation (UE) occurs among 2%–16% of patients with mechanical ventilation (MV). Failed UE requiring reintubation could be associated with several adverse events. Aims: The aim of this study was to investigate the outcomes and prognostic factors of patients with UE in intensive care units (ICUs). Methods: We prospectively registered the patients who had UE and retrospectively reviewed the electronic medical records for 96‐bed ICUs between 1 January 2009, and 31 December 2020. Results: A total of 392 patients had UE, and 234 patients (59.7%) were ≥65 years (older adult group). The median Acute Physiology and Chronic Health Evaluation (APACHE) II score were 17 and the median Glasgow Coma Scale score was 10. In total, 205 patients (52.3%) were reintubated within 48 h (due to failed UE) and 75 patients (19.1%) died during hospitalization. Multivariate analyses were performed to evaluate those factors predicting failed UE and mortality. These analyses demonstrated that higher positive end‐expiratory pressure (PEEP) and the admission APACHE II scores predicted failed UE. A higher fraction of inspiration O2 (FiO2) and minute ventilation; lower haemoglobin (Hb); and higher instances of liver cirrhosis, cancer, and failed UE were independently associated with hospital mortality. Conclusion: We concluded that among patients who had UE, higher FiO2 or minute ventilation, or under MV or with lower Hb, liver cirrhosis, cancer, and failed UE tended to have higher mortality. Relevance to Clinical Practice: Patients with high disease severity indices who have an increased risk of UE required special attention to techniques to prevent endotracheal tubes from accidental removal. [ABSTRACT FROM AUTHOR]

Background: Muted or controlled alarms resulting from alarm fatigue have become a threat to patient safety and several institutions are aware of this risk. Aims: This study aimed to investigate critical care nurses' perceptions of medical device alarms, alarm fatigue, and alarm management practices. Methods: This descriptive study investigated 48 nurses working at two intensive care units (ICUs) within a single university hospital, in South Korea. They were asked to complete a self‐administered questionnaire about their perception of the ICU medical device alarm, alarm fatigue, and related management practices. The response rate was 100%. Results: Critical care nurses experienced a moderate or higher level of alarm fatigue, scoring 29.1 out of 40. Participants identified the items "Frequent false alarms, which lead to reduced attention or response to alarm when they occur," and "Inadequate staff" as the most important issues for alarm management. The most frequently involved item in alarm management practice was "I only use infusion pumps for drugs that require precise dose." Alarm management practices among the nurses differed significantly according to ICU clinical career and experience of patient safety accidents. Conclusions: This study highlights the need to develop a standardized medical device alarm management protocol that can help identify different alarms correctly and respond to them rapidly and appropriately. Relevance to Clinical Practice: It is necessary to reduce alarm fatigue and promote safe and effective alarm management practices among critical care nurses through sufficient education and steady training. Alarm fatigue should also be mitigated by employment of sufficient nursing personnel in ICUs. [ABSTRACT FROM AUTHOR]

Background: Physical assessment skills are essential to clinical decision‐making in nursing as they help nurses to identify and respond to patients' deterioration. Nurses develop confidence and can detect any out‐of‐range parameters in diagnosing and treating patients. Prior studies surveyed 120 skills but did not explicitly assess critical care. Aim: To determine the range of physical assessment skills practised by critical care nurses and their adoption factors. Study design: This study uses a cross‐sectional survey design. A self‐administered questionnaire evaluating 40 physical assessment skills was conducted with 133 staff nurses (response rate: 96.4%) in three critical care units at a Malaysian government hospital between November 2019 and January 2020. Results: Most nurses applied 32 (80%) skills during every working shift, involving the vital signs and all body systems except the gastrointestinal system. Five skills (12.5%) were occasionally applied, while three skills (7.5%) were rarely applied or not part of most nurses' clinical practice. About 20% of the nurses did not routinely check the respiration rate. Medical and surgical intensive care unit nurses (U = 1129, p <.001) and nurses who had served over 10 years (H (2) = 9.60, p =.008) used more physical assessment skills than others. Nurses felt that continuing nursing education, participating in relevant courses and implementing standardised forms to record physical assessments would improve the application of such skills. Conclusion: Clinical practice in these critical care settings challenges the assertion that physical assessment is vital to critical care nursing roles. Concerns highlighted by the nurses should be addressed by nursing management so that the application of physical assessment skills can be enhanced, especially in critical care settings. Relevance to Clinical Practice: The findings indicated that physical assessment skills in critical care need to be improved. Education and training should emphasise these skills. [ABSTRACT FROM AUTHOR]

Background: Nurses in intensive care units (ICUs) play a crucial role in providing palliative care. Effective provision of palliative care in the ICU requires nurses' active engagement, yet little is known about the confidence for palliative care that ICU nurses hold in China. Aim: To explore confidence in performing palliative care among ICU nurses in China and factors related to nurses' level of confidence. Study design: A cross‐sectional design was implemented. Methods: This study utilized convenience sampling to recruit ICU nurses from nine hospitals in Wuhan, China. Data were collected via an online survey. Multiple regression was conducted to identify the predictors of the ICU nurses' confidence in performing palliative care. Results: A total of 231 ICU nurses participated in the study, resulting in a response rate of 78% (231/296). Participants reported a relatively low level of confidence for carrying out palliative care (mean score = 2.60 ± 0.53; range = 1‐4). Nurses who had more positive attitudes toward palliative care communication (P <.001), higher levels of formal training on palliative care (P <.001), more years of working as an ICU nurse (P <.05) and those working in integrated ICU (P <.001) showed a higher level of confidence in carrying out palliative care. Conclusion: Participants' lack of confidence in performing palliative care makes for increased challenges, particularly in uncertainty about family assessments, palliative care discussions and lack of palliative care training. Strengthening palliative care curricula in nursing education and professional training is imperative to enhance ICU nurses' confidence. Relevance to clinical practice: Strengthening palliative care education and training, particularly in relation to palliative care communication, is critical. Implementing and tailoring culturally relevant palliative care call for attention to practice and for policy changes in palliative care delivery in China. [ABSTRACT FROM AUTHOR]

Background: Annually in England, over 1.5 million children and young people (CYP) are admitted to hospital. However, a proportion of these CYP will experience failure to rescue (FtR), a failure to recognize, respond and escalate clinical deterioration, which can result in significant harm or death. Aim: To identify and quantify FtR episodes from emergency events at a 110‐bedded tertiary children's hospital located within a University Teaching Hospital and evaluate the impact of targeted interventions on reducing FtR. Methods: A quality improvement approach was adopted. From 170 446 patients admitted between 2011 and 2019, all emergency event calls were systematically reviewed to identify FtR episodes. Root–cause analysis was performed to identify practice deficiencies. The Plan‐Do‐Study‐Act fundamentals were used. Results: A total of 520 emergency events were reviewed over the 9‐year period. One hundred and thirty‐two (n = 132; 25%) were cardiac arrest events, with the majority occurring within the PCCU setting. Three hundred and twelve (60%) of the events were in children who had been inpatient for more than 48 hours. FtR trend declined over the study period from 23.6% in 2011 when the project commenced to 2.5% or less over the following 8 years. Conclusions: Identifying rates of FtR events from routinely collected emergency events data can be used as a patient safety measure to identify emergency concerns. This enables dynamic problem solving through delivery of strategic and targeted interventions. The proposed interventions outlined in this quality improvement study have application to critical care nursing as mechanisms for reducing unplanned admissions to paediatric critical care unit (PCCU), patient mortality, and PCCU and non‐PCCU cardiac arrests. Relevance to Clinical Practice: This study emphasises the importance in understanding the antecedence of emergency events for paediatric inpatient populations. This intelligence can be used to direct targeted interventions to significantly reduce failure to rescue rates. [ABSTRACT FROM AUTHOR]

Background: Adverse events are often encountered in surgical intensive care units (ICUs), and most of them occur due to preventable errors. Establishment of a patient safety culture is recommended for preventing and reducing these errors. Aims: This study was performed to investigate the relationship between surgical ICU nurses' patient safety culture and adverse events. Design: This was a cross‐sectional descriptive study. Methods: The study was performed in the surgical ICUs of four university hospitals in Izmir province, Turkey and was conducted in accordance with the Declaration of Helsinki and approved by an Ethics Committee. The sample comprised 113 nurses working in the surgical ICUs of the hospitals between November 2018 and February 2019. Data were collected using a questionnaire that comprised a demographic form, adverse events form, and patient safety culture hospital questionnaire. Student's t test, one‐way analysis of variance, and logistic regression analyses were used to evaluate the data. P values <.05 were considered significant. Results: At the end of the study, nurses' level of patient safety culture was found to be intermediate (65.5%), with the highest average positive response rate (PRR) obtained for teamwork within the units (65.5%) and the lowest average PRR obtained for the frequency of adverse event reporting (25.3%). There was a significant correlation between patient safety culture and adverse events (r = 0.027, P <.05). Conclusions: Surgical ICUs nurses' level of patient safety culture was average, and there was a significant correlation between patient safety culture and adverse events. Relevance to clinical practice: Managers should establish a reliable system for reporting adverse events and encourage ICU nurses to report them. It is very important to adopt a non‐punitive approach at instances when an adverse event is reported. [ABSTRACT FROM AUTHOR]

Background: Non‐pharmacologic interventions might be effective to reduce the incidence of delirium in pediatric intensive care units (PICU). Aim: To explore expert opinions and generate informed consensus decisions regarding the content of a non‐pharmacologic delirium bundle to manage delirium in PICU patients. Study design: A two‐round online Delphi study was conducted from February to April 2021. PICU experts (nurses, physicians, researchers, physical therapists, play specialists, and occupational therapists) located in Europe, North America, South America, Asia, and Australia participated. Results: We developed a questionnaire based on the outcomes of a comprehensive literature search in the domains: 1) cognition support; 2) sleep support; and 3) physical activity support. Under these domains, we listed 11 strategies to promote support with 61 interventions. Participants rated the feasibility of each intervention on a 9‐point Likert scale (ranging from 1 strongly disagree to 9 strongly agree). A disagreement index and panel median were calculated to determine the level of agreement among experts. In the second round, participants reassessed the revised statements and ranked the interventions in each domain in order of importance for age groups: 0–2, 3–5, and 6–18 years of age. During the first Delphi round, 53 of 74 (72%) questionnaires were completed, and in the second round 45 of 74 (61%) were completed. Five of the highest ranked interventions across the age groups were: 1) developing a daily routine, 2) adjusting light exposure according to the time of day, 3) scheduling time for sleep, 4) providing eyeglasses and hearing aids if appropriate, 5) encouraging parental presence. Conclusions: Based on expert consensus, we developed an age‐specific non‐pharmacologic delirium bundle of interventions to manage delirium in PICU patients. Relevance to Clinical Practice: An age‐specific Non‐Pharmacological Delirium bundle is now ready to be tested in the PICU and will hopefully reduce pediatric delirium. [ABSTRACT FROM AUTHOR]

Background: Patients in intensive care units (ICU) are frequently prescribed sedatives, which might increase the risk for pressure injury (PI). Although the association between sedation and incidence of PI has been noted, the adequate sedation level to prevent the incidence of PI in patients admitted to ICU is still unclear. Aim: This study aimed to investigate the association between fluctuating sedation levels and the incidence of PI in patients admitted to ICU. Study Design: We retrospectively reviewed the medical records of 104 patients admitted to ICU. Data regarding the length of ICU stay (LOS) and comorbid infection were abstracted from medical records. The Richmond Agitation‐Sedation Scale (RASS) was scored twice per day, and the standardized RASS (S‐RASS, summation of RASS values divided by the number of samples) was used to evaluate changes in sedation levels. Results: Among the 104 included patients, 65 patients (62.5%) were male (median age: 68.0 years), and 13 patients (12.5%) had PI during ICU admission. S‐RASS scores were lower in patients with PI than in those without PI (P =.0001) even after adjustment for confounders (OR [95%CI]: 0.14 [0.03–0.58], P =.006). The LOS and infections were higher in patients with PI than in those without PI (P <.0001 and P =.005, respectively). The cut‐off value of S‐RASS for PI incidence was −3.2 (sensitivity: 88%; specificity: 85%), and a significant predictor of PI incidence (HR [95%CI]: 20.07 [2.53–159.11], P =.005). Conclusions: Deeper sedation levels based on S‐RASS scores, which account for the effects of fluctuating sedation levels, were a strong, highly accurate predictor of PI incidence in patients admitted to ICU. Relevance to Clinical Practice: Assessing fluctuations in the level of sedation using the S‐RASS might help to identify sedative‐induced PI in patients admitted to ICU. [ABSTRACT FROM AUTHOR]

Background: Several nonpharmacological strategies for the prevention and treatment of delirium have been increasingly used because the aetiology of delirium is multifactorial. Aims: To verify the association between nonpharmacological strategies (presence of companion, mobilization, absence of physical restraint and natural light) and the occurrence of delirium, and to identify risk factors for delirium in intensive care unit (ICU) patients. Study Design: The study was conducted in a Brazilian medical and surgical ICU. The sample included patients older than 18 years with length of ICU stay greater than 24 h and without delirium on admission. Delirium was identified by applying the Confusion Assessment Method for the Intensive Care Unit (CAM‐ICU). The association between the variables and delirium was analysed using Mann–Whitney and chi‐square tests, and multivariate logistic regression to identify the predictive factors. Results: Of the 356 patients, 64 (18%) had delirium. The presence of a companion, mobilization, and physical restraint were associated with delirium, and the first two were identified as protective factors. That is, the odds of delirium decreased by 88% when a companion was present and by 95% when the patient was mobilized. The risk factors of delirium were length of ICU stay and age. Conclusions: The presence of a companion and patient mobilization were identified as protective factors against delirium, highlighting their importance as preventive actions, especially in patients with a higher risk of developing this disorder. The findings regarding physical restraint can also be considered evidence indicating the need for careful use of this measure in clinical practice until evidence of its relationship with delirium is confirmed. Relevance to Clinical Practice: The implementation of strategies such as early mobilization, presence of a companion and careful assessment for the use of physical restraint by the multidisciplinary team can help control the occurrence of delirium in the ICU. [ABSTRACT FROM AUTHOR]

Background: An essential element for offering high‐quality care in the intensive care units (ICUs) is the intraprofessional collaboration among nurses, which facilitates the exchange of knowledge and information and hence improves performance. More research is needed to understand the relationship between the nurse–nurse collaboration and job performance in the ICUs due to the multidimensionality of both concepts, the complexity of the ICU environment, and the lack of studies. Aim: To examine the relationship between nurse–nurse collaboration and self‐perceived nurse performance among Jordanian nurses in ICUs. Design: Descriptive, correlational cross‐sectional design was used. Methods: Data were collected through an online survey including the demographic questionnaire, the nurse–nurse collaboration scale, and six‐dimensions scale for nursing performance. Results: In total, 155 critical care nurses participated (response rate = 46.97%). Self‐perceived job performance was significantly associated with gender (t = −3.189, P =.002), age (r = −0.301, P <.01), workplace (F = 28.20, P =.001), the type of ICU (F = 17.70, P =.001), and the number of assigned patients (r = 0.407, P <.01). Among all nurse–nurse collaboration subscales, only the conflict management subscale was an independent significant predictor of self‐perceived nursing performance (t = 3.06, B = 3.066, P =.003). Conclusions: Effective conflict management is associated with better nurse performance, which could ultimately improve patient care in ICUs. Relevance to Clinical Practice: Conflict resolution is an important dimension of optimal nurse–nurse collaboration and has an important effect on nursing performance. Nurses and nurse managers in ICUs need to attend workshops and training programs in conflict management. [ABSTRACT FROM AUTHOR]

Background: The ABCDE bundle is a set of evidence‐based practices to systematically reduce the risks of sedation, delirium, and immobility in intensive care patients. Implementing the bundle improves clinical outcome. Aims and Objectives: To investigate the association between patient outcomes and compliance with bundle components ABC (analgosedation algorithms), D (delirium protocol), and E (early mobilization protocol). Design: A Spanish multicentre cohort study of adult patients receiving invasive mechanical ventilation (IMV) for ≥48 h until extubation. Methods: The primary outcome was pain level, cooperation to permit Medical Research Council Scale administration, patient days of delirium, and mobility. The secondary outcome was cumulative drug dosing by IMV days. Tertiary outcomes (ICU days, IMV days, bed rest days, ICU mortality, ICUAW) and independent variables (analgosedation, delirium, early mobilization protocols) were also studied. Results: Data were collected from 605 patients in 80 ICUs and 5214 patient days with IMV. Two‐thirds of the ICUs studied applied no protocols. Pain was not assessed on 83.6% of patient days. Patient cooperation made scale administration feasible on 20.7% of days. Delirium and immobility were found on 4.2% and 69.9% of days, respectively. Patients had shorter stays in ICUs with bundle protocols and fewer days of IMV in ICUs with delirium and mobilization bundle components (P = 0.006 and P = 0.03, respectively). Analgosedation protocols were associated with more opioid dosing (P = 0.02), and delirium and early mobilization protocols with more propofol (P = 0.001), dexmedetomidine (P = 0.001), and lower benzodiazepine dosing (P = 0.008). Conclusions: The implementation rate of ABCDE bundle components was very low in our Spanish setting, but when implemented, patients had a shorter ICU stay, more analgesia dosing, and lighter sedation. Relevance to clinical practice: Applying some but not all the bundle components, there is increased analgesia and light sedation drug use, decreased benzodiazepines, and increased patient cooperation and mobility, resulting in a shorter ICU stay and fewer days of IMV. [ABSTRACT FROM AUTHOR]

Background: Sleep disturbance negatively affects recovery and survival of patients in intensive care units (ICUs). Aims and Objectives: This study aimed to measure the noise levels and evaluate the impact of a white noise app on the sleep quality of critically ill patients. Design: A quasi‐experimental time series pre‐test–post‐test control group design with repeated measures was adopted. Methods: The study was conducted in the high dependency unit (HDU) of a selected tertiary care hospital in Mangalore, Karnataka State, India. Conscious oriented patients with systolic blood pressure ranging from 100/70 to 140/90 mm Hg and hearing acuity of at most 20 dB in both ears were included in the study. Noise levels in the HDU were measured using calibrated sound level meter on weekdays/weekends in three different shifts and an average of 24 readings was obtained per shift. A 4‐point Likert scale was used to assess the sleep quality. The intervention included administration of white noise app twice a day, for three consecutive days by using different masking sounds such as white noise on day 1 which resembles to a humming AC conditioner, pink noise on day 2 which resembles to the sound of ocean waves and brown noise on day 3 which resembles a steady rainfall. The app was used with the help of JBL earphones C10SI an excellent noise cancellation and noise isolating earphone. Results: Among the 54 subjects, the mean age of the patients was 40.28 years, majority 34 (63%) were males. The noise level in the ICU was more than 60 dB. There was a significant difference in the sleep quality after the application of the white noise app in the experimental group on Day 1 (Z = −3.996; P =.001), Day 2 (Z = −3.302; P =.001), and Day 3 (−2.822; P =.005) compared to the control group. Conclusion: Adoption of technology driven noise reduction applications would enhance the quality of sleep among the ICU patients. Relevance to clinical practice: The use of a technology‐driven application helps control noise levels which promotes improved sleep quality among critically ill patients in the intensive care units. [ABSTRACT FROM AUTHOR]

Background: Situation‐Background‐Assessment‐Recommendation (SBAR) is a tool for structuring communication between healthcare professionals. SBAR reduces medical errors, however few studies have evaluated its quality in real practice. Aims: To describe the quality of SBAR utilization by intensive care unit (ICU) nurses during phone conversations with physicians. To assess the influence of nurses' training, professional experience, and call circumstances on this quality. Study Design: This observational study was conducted in the adult ICU of a university hospital in French speaking Switzerland. All consecutive telephone calls from nurses to physicians during a calendar month, were recorded. Those related to a change in patients' clinical status were selected and analysed. The quality of SBAR utilization was assessed using a pre‐defined analysis grid. Scores ranged from 0 (worst quality) to 100% (best quality). Nurses' sociodemographics and training record were collected. Multiple regression was used to assess determinants of SBAR quality including nurses characteristics and level of training. Results: We analysed 290 phone calls, made by 99 nurses. The median SBAR quality score was 41% (interquartile range [IQR] 33–48). Quality scores varied across the four items of SBAR: Situation 88% (81–94), Background 17% (6–27), Assessment 17% (0–33), and Recommendation 33% (17–40). Factors independently associated with higher SBAR quality were age (−0.66%, p =.002, 95% CI [−1.07; −0.25]), primary language other than French (−8.40%, p =.017, 95% CI [−15.29; −1.51]), lack of ICU expertise (−9.25%, p =.013, 95% CI [−16.5;1–1.99]), and SBAR training in pre‐graduate nursing education (+11.53%, p =.028, 95% CI [1.27; 22.79]). Conclusions: The quality of SBAR utilization remains low in ICU clinical practice. Pre‐ and post‐graduate training seem to improve its quality. Relevance to Clinical Practice: Pre‐graduate mandatory training associated with multiple repetitions could improve nurses' SBAR utilization. Training using the SBAR tool should be combined with the development of nursing skills in assessment and clinical judgment. [ABSTRACT FROM AUTHOR]